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PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via email with our monthly newsletter, promotions, contests, and prizes. Should you be accepted for care, do you wish to have appointment reminders sent to the email address provided above? Yes No (please initial) Birth Date: (DD-MM-YYYY) - - Age: Male: Female: Occupation: Employer: Marital Status: Spouse s Name: Previous Chiropractor: Last visit to the Chiropractor: City: Reason for leaving: Present MD: City: Referred to our Centre by:

MERIVALE CHIROPRACTIC CLINIC Our Fee Structure Please note our fees for your initial visit: Consultation Complimentary Examination $150.00 Radiology $0.00-$84.00 (subsidized by OHIP) X-Ray Report $30.00 Adjustment /Visit $50.00 Modality / Traction $25.00 (in addition to regular visit fee) Year End Progress Exam $45.00 Acupuncture with Adjustment $25.00 (in addition to regular visit fee) Acupuncture 15 minute $50.00 30 minute $60.00 45 minute $80.00 1 hour $100.00 Motor Vehicle Accident FSCO Submission Fee $45.00 (one-time fee) Please note that if you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. Please also note that your clinical Report of Findings, the time that your doctor will spend with you to go over your results, will be included in your initial fee. I fully understand the above fees and give my consent. I also give my consent to have the doctor take any x-rays he/she deems appropriate to better understand my problem and monitor my progress. Who is responsible for your bill: You: Spouse: Auto Ins.: WSIB: Extended Health Ins.: SIGNATURE: DATE: (Signature of Parent/Guardian required if patient under age 18) Thank You!

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:

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? Do you have any children? # of children: Children s Names: Do they have any health problems that you are aware of? Is there any other information you would like us to know? SIGNATURE: DATE: For Women Only Date of your last menstrual period: Are using any means of contraception? Do you suffer from PMS? Do you experience severe cramping with your menstrual period? Thank You!

MCC SYMPTOM DIAGRAM Patient Name: File #: Date: In the diagrams provided below, please mark the areas on your body, which you feel best represent the pain(s) or sensation(s) you are experiencing. Please include all areas. Use the symbols provided below. Also, in order to complete the picture, please draw in your face. Symbols: Numbness Pins & Needles Burning Stabbing & Sharp Dull & Aching Stiff & Tight

HEALTH STATUS SURVEY Patient Name: File #: Date: Please circle (O) any conditions or symptoms presently causing you problems. Please check ( ) those conditions or symptoms, which have been a problem to you in the past. GENERAL SYMPTOMS Loss of consciousness Blackouts Headache Fever Sweats Fainting Dizziness Clumsiness Convulsions Loss of sleep Numbness, pain or tingling Nervousness Loss of weight MUSCLES & JOINTS Stiff neck Backache Swollen joints Painful tailbone Foot trouble Shoulder pain Arm/Forearm pain Elbow pain Wrist pain Hand pain Arthritis Weakness or loss of strength E.E.N.T. Blurred vision Failing vision (one/both eyes) Crossed eyes Double vision Eye pain Deafness, Earache Ringing, buzzing, any noise in the ears Asthma Frequent colds Sinus infection Enlarged glands Enlarged thyroid Slurred or other speech problems Difficulty swallowing RESPIRATORY Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing CARDIOVASCULAR Bleeding Disorder High blood pressure Pain over heart Stroke Hardening of arteries Varicose veins Swelling of ankles Poor circulation Heart or blood disease Angina GENTOURINARY Trouble urinating Blood in urine Kidney infection Bed-wetting Prostate trouble G.U. FOR WOMEN Painful menstruation Excessive flow Hot flashes Irregular cycle Cramps or backache Vaginal, discharge Swollen breasts Lumps in breasts Have you ever been on birth control pills? Yes No Are you currently taking the birth control pill? Yes No # of pregnancies # of children Please inform the doctor if you have ever been tested for HIV or Hepatitis A/B/C. SKIN Rashes, itching Bruise easily Dryness Boils Hives (allergy) GASTROINTESTINAL Poor appetite Indigestion Excessive hunger Belching or gas Nausea Vomiting (blood?) Pain over stomach Constipation Diarrhea Hemorrhoids (piles) Jaundice Gall bladder trouble Intestinal worms Ulcer Diabetes Have you ever had any fractures? Yes No Have you ever been in a car accident? Yes No Have you ever been hospitalized? Yes No If yes, why? Are you currently a smoker? Yes No Have you ever smoked in the past? Yes No Have you ever been diagnosed with cancer? Yes No Do you take medication on a regular basis? Yes No If so, what? (blood thinner, blood pressure, etc.)

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