WELCOME TO The Chiropractors at Commerce Place For Office Use Only live well adjusted Doctor: Date: _ Referred by: MVA WCB Date of injury: Previous Chiro Care: Y / N Previous Chiro: _ Last adj date: Spine X-rays? Y / N When: Facility: New Patient History Form - Adult Please relax, breathe and smile. We are happy to have you here! WHY THIS FORM IS IMPORTANT In our Clinic, we focus on your ability to be healthy. Our goals are, first to address the issues that brought you to this office and second, to offer you the opportunity of improved health and wellness in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health. Most times the effects are gradual, not even felt until they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to your health potential. PERSONAL INFORMATION Name: _ Mr. Mrs. Miss. Ms. Dr. Last First Initial Prefer to be called: Alberta Health Care #:_ Email Address (for appointment reminders only): *optional* Home ph:() Business ph:() Cell ph:() Address: City: Province: Postal Code: Birth Date: Day / Month / Year Age: Sex: M F Height: Weight: Please check one: Single Married Separated Divorced Widowed Common Law Occupation: Number of children: Who can we contact in case of an emergency? Name/number: CURRENT HEALTH INFORMATION Why are you consulting our office? Do you want better health for yourself on a long-term or temporary basis? Long-term Temporary What is your level of commitment to yourself, your life and your well-being? Very committed Somewhat committed Not committed Are you healthier now than you were 5 years ago? Yes No In 5 years do you want to be healthier than you are right now? Yes No
LIFESTYLE INFORMATION Yes No Are you frequently ill? Yes No Do you often feel exhausted? Yes No Do you have trouble sleeping? Yes No Are you pregnant or trying to get pregnant? Yes No Have you ever been told you have cancer? Yes No Do you currently smoke? If yes, packs/day: Yes No Do you drink alcohol? If yes, drinks/week: Yes No Do you drink coffee? If yes, cups/day: Yes No Do you drink pop? If yes, cans/week: Are you currently on a program of: (check all that apply) vitamins minerals herbs diet exercise others? How long has it been since you felt really good? days weeks months years too long On a scale of 1-10 describe your stress level: (0=no stress 10=high stress) Occupational stress: /10 Personal stress: /10 What is your estimation of your present general health? poor fair good excellent Please list any previous or present illnesses or surgeries: BODY STRESS EVALUATION Lifestyle stress occurs in three dimensions - physical, bio-chemical, and psychological. When you experience these stresses beyond the body s ability to cope and adapt, it has an impact on the nervous system by causing subluxation (misaligned vertebra). Please check ( ) all stresses that you have experienced, no matter how long ago, mild, or few your exposure may have been. 1. BIO-CHEMICAL STRESS: Environmental pollution (air, water, etc.) Chemical exposure (solvents, fumes) Smoker Second-hand smoke Poor diet Caffeine (e.g. coffee, pop) Excessive sugar Alcohol/Drugs Artificial sweeteners Fast food Prescription drugs Over-the-counter drugs (i.e. Tylenol, Advil) 2. PSYCHOLOGICAL STRESS: Relationships Career Children Money Fast-paced life Internalize feelings Procrastinator Sickness or loss of a loved one Perfectionist Quick temper Verbal abuse Nervous / anxious person 3. PHYSICAL STRESS: Slips / falls Birth traumas (as a mother or child) Car accidents Knocked unconscious Sports injuries Poor posture Overweight Sitting on your wallet Sleeping position - stomach Extensive computer work Carrying heavy purse / book bag / child Repetitive lifting / bending Continuous sitting / standing Broken bone(s) / surgery Physical abuse Work injuries TOTAL STRESS: _ Add checkmarks from bio-chemical, psychological, and physical stresses
MEDICATIONS I AM TAKING Pain Killers (incl. Aspirin, Tylenol, etc.) Muscle relaxers Blood pressure pills Antidepressants Others: FAMILY HEALTH HISTORY Arthritis Heart disease High blood pressure Diabetes Cancer Stroke Others: SYMPTOMS: PAST AND PRESENT PLEASE CIRCLE ANYTHING WHICH IS CURRENTLY CAUSING YOU PROBLEMS OR HAS BEEN A PROBLEM IN THE PAST 6 MONTHS GENERAL PROBLEMS Headache Fever Sweats Fainting Dizziness Sleeping problems Weight Loss / Gain Depression Food cravings Fatigue Mood swings Nervousness Irritability Tension Loss of balance CARDIOVASCULAR Blood Pressure Problems Stroke Heart Condition MUSCLES & JOINTS Back Pain / Stiffness Neck Pain / Stiffness Numbness in fingers Numbness in toes Pins and needles in arms Pins and needles in legs EYE/ EAR/ NOSE/ THROAT Vision problems Jaw Clicking / Pain Ringing in ears Earaches Frequent Colds Sinus Problems Speech Problems Allergies Loss of smell Loss of taste RESPIRATORY Chest Pain Difficulty Breathing Asthma GASTROINTESTINAL Ulcer Diabetes Poor / Excessive Appetite Indigestion Belching or Gas Constipation Diarrhea Irritable Bowel Heartburn Gallstones Blood in Stool GENITOURINARY Problems Urinating Bed Wetting G.U. FOR WOMEN Hot Flashes Menstrual pain Menstrual Irregularity Fertility/Pregnancy Problems FOR DOCTOR USE ONLY PRESENTING COMPLAINT: ONSET: INTENSITY/CHARACTER: mild moderate severe LOCATION: AGGRAVATING: RELIEVING: RADIATION/REFERRAL: No pain radiation/radicular sx s noted ASSOCIATED / SECONDARY S&S FREQUENCY: DURATION: PAST/FAMILY HISTORY:
CANADIAN CHIROPRACTIC PROTECTIVE ASSOCIATION CONSENT TO CHIROPRACTIC TREATMENT FORM L It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise. Benefits Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery. Risks The risks associated with chiropractic treatment vary according to each patient s condition as well as the location and type of treatment. The risks include: Temporary worsening of symptoms Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days. Sprain or strain Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care. Rib fracture While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention. Injury or aggravation of a disc Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while. Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a preexisting disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed. Stroke Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke. CCPA 09.14
Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain. Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death. Alternatives Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment. Questions or Concerns You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition. DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me. Name (Please Print) Signature of patient (or legal guardian) Signature of Chiropractor Date: 20. Date: 20. Date: 20. CCPA 09.14