Patient Introduction (age 13-21)
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- Bryan Hensley
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1 #204, 1740 Gordon Drive Kelowna, BC V1Y 3H Patient Introduction (age 13-21) Personal History: Your Name: First (Nick-name) Last Your Mom: Sibling: Sibling: Your Dad: Sibling: Sibling: Your Mailing Address (including postal code please): Phone/Home: Your Cell: Mom s cell: Dad s cell: _ Your Birth Date: Day: Month: Year: Age Occupation: Employer: Previous Chiropractor: Last visit to this Chiropractor: City: Reason for leaving: Present MD: City: Referred to our Centre by:
2 #204, 1740 Gordon Drive Kelowna, BC V1Y 3H Adult Consultation History Your Name: Your Main Complaint: Any other Complaints: How long have you suffered with this problem? What have you tried to do to get rid of this problem that DID NOT work? Have you become discouraged about handling this problem? When your problem is at its worst, how does it make you feel? How does this problem interfere with the following areas of your life? WORK: FAMILY: HOBBIES: LIFE: Does handling this problem cause stress for you? What do you do that makes this problem worse? How much older does this make you feel: On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem: Page 1 of 2 (double sided)
3 What gives you some temporary relief? What is the pattern of this problem? Constant, Intermittent, Occasional Cyclic What is the effect it has on your body functions? How did it start? Are you on any type of medication?, Please list all: Could your problem have been caused by an injury at work? If yes, please give us the details: Have you been involved in an auto accident? Date of accident: Any difficulties from this? Is there any other information you would like us to know? Do you have any children? Do they have any health problems that you are aware of? SIGNATURE: DATE: For Women Only Date of your last menstrual period: Are using any means of contraception? Do you experience severe cramping with your menstrual period? Do you suffer from PMS? Thank You! Page 2 of 2 (double sided)
4 FAMILY HEALTH HISTORY Patient Name: Date: _ Please review the diseases and conditions listed below and indicate those that are current health problems of a family member by the designation C under his or her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply. Condition Self Father Mother Spouse Children Age Age Age ADHD Allergies Arthritis Asthma Autism Back Trouble Bed Wetting Bursitis Cancer Chest Pain Colic Constipation Crohn Disease Depression Diabetes Diarrhea Disc Problems Down Syndrome Ear Infection Emotion Issues Emphysema Epilepsy Headaches Migraines Heartburn Heart Trouble High Blood Press IBS Indigestion Infertility Insomnia Kidney Trouble Neck Pain Neuritis Nervousness Pinched Nerve Scoliosis Sinus Trouble Other Additional Comments:
5 Choosing chiropractic care is an exciting step towards regaining or improving your health and wellness. Old injuries, emotional tension, work and family situations along with poor dietary choices add to your daily stress load. This can cause muscles to overreact and joints within the spine to lock. However, our greatest concern is when those ongoing stressful habits affect the inner nerve connections, leaving you at risk for deeper health problems. Unwinding harmful spinal stress while coaching you towards a strong and vibrant lifestyle is what we love to do! Our uses a sophisticated scanning system to detect hidden stress patterns. This accurate, computer-based analysis rates your stress on a scale from and is known as the COREscoreTM. Please answer the following questions so we may better understand how to help you: 1. On a scale of 1 to 10 (10 being the most important) how important is your health to you? On the COREscoreTM chart to the right: 2. Please put an X to score where you think you are today. 3. Please circle where you would like to be (your goal). 4. How long do you think it might take to get to where you circled? _ 5. What things might you need to change to help you reach your goal? a. _ b. _ c. _ d. _ 6. If we could make recommendations that would not only address your main concerns, but could also help you with improving your overall health, would you like to hear them? yes no EXCELLENT VERY GOOD GOOD TRANSITION CHALLENGED 0-59 VERY CHALLENGED
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