Name (as appears on Medicare card)Date MM slash DD slash YYYY Mobile Phone: *Work Phone:Home Phone:StreetCity/SuburbState/ProvinceSpouse DOB? MM slash DD slash YYYY Age: *M/F/OtherEmail:* Name/s of Children and DOB:Occupation:Employed by:Who Is Responsible For Account?Do You Have Private Health Insurance With Extras Cover Yes No Is Your Present Condition Covered By Workers Compensation? Yes No Emergency Contact: NameEmergency Contact Person NumberWho referred you to us?Referred By Friend/Relation Internet Facebook Other (Please describe) Signature:Max. file size: 256 MB. Patient Case HistoryDear Patient: Please complete this questionnaire. Your answers will help us to determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.THIS IS A CONFIDENTIAL HEALTH AND ILLNESS REPORT IMPACT OF YOUR SYMPTOMSHow is this symptom/condition interfering with your life? (Tick appropriate box.)Work No Effect Mild Effect Moderate Effect Severe Effect Energy No Effect Mild Effect Moderate Effect Severe Effect Exercise No Effect Mild Effect Moderate Effect Severe Effect Attitude No Effect Mild Effect Moderate Effect Severe Effect Recreation No Effect Mild Effect Moderate Effect Severe Effect Patience No Effect Mild Effect Moderate Effect Severe Effect Relationships No Effect Mild Effect Moderate Effect Severe Effect Productivity No Effect Mild Effect Moderate Effect Severe Effect Sleep No Effect Mild Effect Moderate Effect Severe Effect Creativity No Effect Mild Effect Moderate Effect Severe Effect Self-Care No Effect Mild Effect Moderate Effect Severe Effect Other No Effect Mild Effect Moderate Effect Severe Effect How committed are you to correcting this issue? 1 2 3 4 5 6 7 8 9 10 PLEASE TAKE A MOMENT TO UNDERSTAND THE DIAGRAM ABOVE.A. What number do you think represents your health today? 1 2 3 4 5 6 7 8 9 10 B. In what direction is your health currently headed? Gettingmuch worse Getting worse Staying about the same Getting better Getting much better Other (Please describe) PLEASE TAKE A MOMENT TO UNDERSTAND THE DIAGRAM ABOVE.1. IMMEDIATE Relief of symptoms Back to work Other (Please describe) 2. SHORT TERM Correction of underlying problem Well-functioning spine and nervous system Other (Please describe) 3. LONG TERM Healthy and fully functioning body Maintaining your best health Living a wellness lifestyle Other (Please describe) TICK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD OR HAVE NOWGENERAL Allergy Dizziness Fatigue Headache Loss of sleep Nervousness/depression Numbness Stroke Diabetes GASTRO-INTESTINAL Belching or gas Colon trouble Constipation Diarrhea Difficult digestion Gall bladder trouble Hemorrhoids Liver trouble Nausea Poor appetite Hiatus Hernia RESPIRATORY Chest pain Chronic cough Difficult breathing Asthma SKIN Bruise easily Dryness Itching Psoriasis MUSCLE AND JOINT Low back pain Neck pain or stiffness Pain between shoulders Swollen joints/Arthritis Arm pain Leg pain Knee pain Foot pain Ankle pain Hand pain EYES, EARS, NOSE & THROAT Earaches Enlarged glands Eye pain Sinus problems Blurred vision Hearing loss GENITO-URINARY Bed wetting Frequent urination Painful urination Kidney infection Prostate trouble Testicular pain WOMEN ONLY Bed wetting Frequent urination Painful urination Kidney infection Prostate trouble Testicular pain CARDIO-VASCULAR Blood pressure Poor circulation Rapid heart beat Slow heart beat Swelling of ankles History of Heart Attack TRAUMAS Car, bike or auto accident Sport injury Work injury Front sleeping Falls – stairs, wet tiles etc. Repetitive strain injury Birth forceps/vacuum delivery Have you been in a motor vehicle accident? Past year Past 5 years Over 5 years Never Describe (front end/rear-end/T-bone? + any symptoms)Have you had chiropractic care before? Yes No What is your major complaint?How long have you had this condition? When did it first start and why?What relieves your condition?What activities aggravate your condition?Is this condition getting progressively worse? Yes No Constant Comes and goes Is this condition interfering with your: other – please list Work Sleep Daily routine Other (Please describe) Other complaints (Please list all and describe, e.g. Mid back on left side, sharp pain, intermittent, 3 years, aggravated by sitting long and worse in mornings.)How long has it been since you felt good?List surgical operations and years:Are you pregnant? Yes No Exercise programs & sportsYour medical Doctor’s name and name of clinicDO YOU: Now take vitamins or minerals?Describe/List themNow take drugs of any kind?Describe/List themDATE OF LAST Spinal examination Less than 6 months 6-18 months Over 18 months Never Physical examination Less than 6 months 6-18 months Over 18 months Never Blood test Less than 6 months 6-18 months Over 18 months Never Chest x-ray Less than 6 months 6-18 months Over 18 months Never Spinal x-ray Less than 6 months 6-18 months Over 18 months Never Dental x-ray Less than 6 months 6-18 months Over 18 months Never Urine test Less than 6 months 6-18 months Over 18 months Never Please Bring Your Medicare Card To Your ConsultationMedicare NameMedicare NumberMedicare CardMax. file size: 256 MB.
