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Transcription:

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address: I hereby authorize Taunton Chiropractic and Health Centre, with my prior knowledge, to release to or obtain any health information from my other healthcare providers as may be required for the management of my case. I have read and understand the Taunton Chiropractic and Health Centre fee schedule and cancellation policy. I am aware that if insurance claims are being submitted on my behalf that I am responsible for any outstanding balance not covered by my insurance policy. Client Signature:

Date of Last Appointment or physical: Occupation: What do you do mostly? (sit/stand/etc.) Height: Weight: How did you hear about our clinic? Please describe your present complaint: When did it occur? How did it occur? Have you received any treatment for this condition, and if so what kind of treatment? Has any treatment helped? _ Have you ever had a similar problem to your current complaint? Were X-rays taken? YES NO Have you been to a chiropractor before? Y / N Was this an injury that occurred at work? Y / N When was your last treatment? Was it reported? Y / N Was this an injury as a result of a car accident? Y / N Is there a claim pending? Y / N Do you currently smoke? Y / N How often do you exercise and what type of activity is it? times/week Any Prior Surgery? Prior Hospitalizations? Have you broken any bones?

Do you currently take any prescription or over the counter medications or vitamins/nutritional supplements? Y / N Specify: What would you like to achieve by coming to our clinic? (Our primary goal is always to work toward the resolution of your condition as quickly as possible!) Do you have any concerns about the therapy that you would like us to address before we begin treatment? (We believe that good client communication is essential and we always want to know your perspectives positive or negative.) Females Only: Date of last menstrual period? Are you currently pregnant? Y / N Have you ever taken birth control pills? Are you currently taking birth control pills? How many children do you have? How many pregnancies?

Family Health History File# Have your grandparents, parents or siblings ever been diagnosed with any of the following? High blood pressure Heart disease Stroke Diabetes (Type I or TypeII) Thyroid / Hormone problems Breathing or lung problems Rheumatoid Arthritis Osteoarthritis Neurological problems Cancer Kidney Disease Other specify: Client Health History *Please check anything which is causing you problems right now* *Please circle anything which as been a problem in the past* Persistent fatigue Chronic Cough Rashes Headache Spitting up Blood Itching Fever Chest Pain Bruise Easily Sweats Difficulty Breathing Skin Dryness Fainting Boils Dizziness Blurred Vision Hives (allergy) Loss of Sleep Double Vision Numbness Deafness Ulcer Tingling Earache Diabetes Weight Loss Asthma Poor Appetite Pain Frequent Colds Indigestion Sinus Problems Excessive Hunger Back Ache Enlarged Glands Belching or Gas Swollen Joints Speech Problems Nausea Foot Pain L / R Difficulty Swallowing Vomiting Shoulder Pain L / R Seizures/Epilepsy Pain Over Stomach Elbow Pain L / R Bleeding Disorder Constipation Wrist Pain L / R High Blood Pressure Diarrhea Hand Pain L / R Stroke Hemorrhoids Hip Pain L / R Varicose Veins Jaundice Knee Pain L / R Hardening of Arteries Gallbladder Problem Arthritis Swelling of Ankles Bed Wetting Weakness Heart or Blood Disease Frequent Urination Loss of Strength Heat/Cold Intolerance Difficulty Urinating TMJ Problems L / R High Cholesterol Blood in Urine Kidney Infection Breast Lump/Pain Severe Menstrual Cramps Hot Flashes Irregular Cycle

Name: Date: INDICATE THE SEVERITY OF YOUR SYMPTOMS 0 5 10 No Symptoms Extreme Symptoms PLEASE CIRCLE YOUR AREA OF COMPLAINT AND INDICATE THE TYPE OF SYMPTOM AND IT S SEVERITY. ACHE X X X X X X STIFFNESS * * * * * * STABBING 2 2 2 2 2 2 NUMBNESS + + + + + + PINS & NEEDLES 0 0 0 0 0 0

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