New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4
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1 New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4 Date: Name Age Date of Birth Address Postal Code Occupation Phone (home) (work) Okay to leave a message? Y / N Marital Status: Single Married Divorced Separated Widow Other: Number of Children Emergency Contact Relation Phone How did you find out about our clinic? Friend Medical Doctor Website OAND CAND Other: Last physician or health practitioner seen? When? When was your last physical exam? Were blood tests done? Y / N Please list your chief health concerns in order of importance: What kinds of conventional treatments have you received for these: Please list all medications (prescription and over the counter) and natural products (vitamins, herbs, oils) currently taking: Medication/Natural Product Dose/Quantity per day Reason for use Have you ever used any of the following, please check:
2 Antibiotics Corticosteroids Chemotherapy/radiation Antacids Antihistamines Pain reliever (aspirin) Arthritis drugs (Vioxx) Hormone therapy (including fertility treatments) Thyroid medication Blood thinners Antidepressants Diuretics Anesthesia Sleeping pills Epidural Recreational drugs Laxatives Please circle any of the following complementary health care practitioners you have or are currently seeing: Naturopathic Doctor Chiropractor Acupuncturist Massage Therapist Osteopath Psychologist Other: Your Health History What is your general state of health? Please circle one: Excellent Good Average Fair Poor What is your current energy level 1-10? (10 being the best you have ever felt): What is your current weight? One year ago? Ideal? Height? Please list any allergies or sensitivities that you have currently or previously experienced: Indicate which of the following conditions you have you had and indicate now (N) or past (P) Condition Now Past Condition Now Past SKIN & HAIR Acne Excessive hair growth Eczema Alopecia Psoriasis Hives EYES Do you wear glasses or Floaters
3 contacts? Impaired vision or blurring Cataracts EAR NOSE AND THROAT Ear infections Impaired hearing Tinnitus/ringing in ears Ruptured ear drum Excess ear wax Frequent nose bleeds Nasal or sinus congestion Tonsillitis Sinusitis RESPIRATORY Asthma Cough Pneumonia Tuberculosis CARDIOVASCULAR Chest pain/angina Heart disease High blood pressure Leg swelling/edema GASTROINTESTINAL Nausea or vomiting Acid reflux/gerd Indigestion Gas/bloating Gallstones/removal Ulcerative Colitis/Crohns MUSCULOSKELETAL Arthritis Gout Broken bones Rheumatoid Arthritis Muscle cramps/weakness NEUROLOGICAL Headaches/migraines Fainting Balance problems Poor Memory Glaucoma Macular Degeneration Frequent colds Hoarseness Strep throat Whooping cough Hay fever Measles Mumps Bleeding gums Canker sores COPD Emphysema Chronic bronchitis Shortness of breath High cholesterol Varicose veins Arrhythmia Pace Maker Constipation Hemorrhoids Hernia Diarrhea Irritable bowel syndrome Rectal bleeding Back pain Carpal tunnel syndrome Osteoporosis Osteoarthritis Sciatica/nerve pain Seizures Slurred speech Loss of sensation Numbness/Tingling
4 MENTAL/EMOTIONAL Anxiety Bipolar disorder Depression Obsessive compulsive disorder Schizophrenia Phobia Thoughts of suicide Insomnia ENDOCRINE Anemia Fatigue Temperature sensitivity Hot flashes WOMENS HEALTH Breast lumps Breast pain/tenderness Nipple discharge Breast cancer PMS Irregular menses Menstrual cramps Endometriosis Vaginal Itching/discharge Yeast infection Pain with intercourse Ovarian cysts Infertility MENS HEALTH BPH-prostate enlargement Difficulty urinating Prostate cancer Testicular pain/masses URINARY Kidney disease Kidney stones Incontinence Excessive stress Substance abuse Child abuse Physical abuse Sexual abuse Emotional abuse Rape Alcoholism Diabetes Thyroid problems Diabetes Excessive sweating Are you sexually active? Do you use birth control Birth control pill Barrier method Tubal ligation Abnormal PAP Number of pregnancies Number of miscarriages Number of abortions Age of first period Age of menopause Menopause symptoms Hormone replacement therapy Erectile dysfunction Penile lesions Penile discharge Fertility issues Blood in urine Frequent UTIs Pain/burning on urination
5 Family History: please write any medical conditions your family members may have. This includes parents, grandparents, siblings and children. Family Member Condition Diet Please list any dietary restrictions Exercise How many times do you exercise per week? What type of activities? Vaccinations (please check all that apply): Polio Hepatitis B Hepatitis A Varicella (chicken pox) Haemophilus Influenza B MMR (measles, mumps, rubella) HPV (human papillomavirus) DPT (diphtheria, pertussis, tetanus) Meningococcal C conjugate (meningitis) Pneumococcal conjugate (meningitis, pneumonia) Flu vaccine Tetanus booster BCG (tuberculosis) Arthritis drugs (Vioxx) Hormone therapy (including fertility treatments) Thyroid medication Thank you for taking the time to complete this form.
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