ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

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ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone: Business Phone: Cell Phone: Email Address: Occupation: Employer s Address: Emergency Contact Name and Phone Number: Is this a WCB Claim? YES or NO Is this a Motor Vehicle Accident? YES or NO If this is either a WCB Claim or a Motor Vehicle Accident, please give the date of the accident. Last Chiropractic Adjustment: Doctor s Name: Date: Were you referred to this office? YES or NO By Whom? What is your major complaint / reason for coming into our office? Please circle the type of mattress you sleep on: Foam Mattress Box Spring Waterbed Other Have you been a resident of Alberta for 3 months? YES or NO Do you have Group Benefits? YES or NO Through Whom? This Section Is For Office Use Only. Alberta Health Care: Group Benefits:

Personal Health History Please check all conditions that you may experience, if the symptom does not apply to you, leave it blank. ** O = Occasional F = Frequent C = Constant ** GENERAL O F C ENDOCRINE O F C Allergies / Asthma Weight Gain Food Sensitivities / Intolerances Coarse Hair Rash Dry / Scaly Skin Stress Intolerance to Heat Depression Intolerance to Cold Muscle soreness after exercise Mentally Sluggish Fever Decreased Appetite Chills Increased Appetite Sweats Difficulty Gaining Weight Fatigue Nervousness Weight Loss / Weight Gain Thin, Moist Skin Pain that wakes you from sleep Brown Spots on Skin Cough / Cold / Flu Poor Circulation Headaches Intestinal Troubles Nausea / Vomiting Low Blood Pressure Dizziness (Spinning, light-headed or faint) High Blood Pressure Feet cracking or peeling Salt Cravings Strong Foot Odor Respiratory Disorders CARDIORESPIRATORY O F C GASTROINTESTINAL O F C Chest Pain Sore Tongue Pain with deep breaths Diarrhea Rapid Heartbeat Constipation Heart feels like it skips a beat Bloating Difficulty Breathing / Shortness of Breath Belching / Gas Chronic Cough Cramping Productive Cough (Sputum, phlegm or blood) Heartburn Swollen Ankles Hemorrhoids Leg Cramps Rectal Bleeding Cold Hands or Feet Unusual Stool Color Bruises Easily Yellow Skin or Eyes NEUROLOGICAL O F C Upset Stomach from eating fatty foods Vision Problems Itchy Skin or Feet Swallowing Problems LYMPH NODES / GLANDS O F C Speech Problems Enlarged Lymph Nodes / Glands Balance Problems (walking difficulties) Painful Lymph Nodes / Glands Numbness GENITOURINARY O F C Falling Down Painful Urination Loss of Consciousness Unusual Urine Color Incoordination of Arms and/or Legs Frequent Urination FEMALES ONLY O F C Accidental / Uncontrollable Urination Painful / Swollen Breasts Sense of Urgency to Urinate Breast Lumps MALES ONLY O F C Frequent / Prolonged Menstruation Trouble Starting / Stopping Urination Absent Menstrual Periods Dribble After Urinating Painful Menstruation Incomplete Urination PMS

ALL PATIENTS Please indicate if your condition (including headaches) is made worse by the following: Exercise Coughing, Sneezing or Straining Alcohol Eating or After Meals Certain body positions such as PAST HEALTH HISTORY Please read carefully and indicate if you have been diagnosed with any of the following conditions: Ankylosing Spondylitis (Marie Strumpell s) Atherosclerosis (Cardiovascular Disease) Cancer Diabetes Down Syndrome Enteropathic Arthritis Gallstones Heart Attack (Myocardial Infarction) Heart Disease High Blood Pressure Hyperlipidemia (High Cholesterol) Marfan s Disease Osteopenia or Osteoporosis Psoriatic Arthritis Reiter s Syndrome Arthritis Stroke Systemic Lupus Erythematosus Eczema / Psoriasis List any serious illnesses or injuries you have had. Have you been hospitalized in the last 5 years? YES NO If yes, for what reason? List any surgeries you have had. Are you under the care of a Medical Doctor? YES NO Name: Number: Please indicate any prescription medications you currently take: Birth Control Blood Thinners Steroids Other (Please Specify) Indicate any over the counter medications you take: Aspirin (how often?) Acetaminophen (how often?) Ibuprofen (how often?) Other (Please Specify) Please indicate if you use / consume any of the following? Tobacco Products: How many packs per week? For how long? Alcohol: How much per week? Recreational Drugs: Type and amount? Caffeine: Amount per day? FAMILY HEALTH HISTORY Please indicate if anyone in your family has been diagnosed with any of the following conditions: Cancer Diabetes Heart Disease High Blood Pressure Stroke Osteoporosis Please list any other serious illnesses any of your family members have been diagnosed with. THANK YOU! Your responses will assist us in determining the most appropriate course of action for your care.

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