Consultation Admittance Form Chiropractic Care Page 1 Page 2 Order Number Last Name: First Name: Gender: Male Female Address: City / Province: Postal Code: Phone (Home) Phone (Work) Phone (Cell) Alberta Health Care # Third Party Insurance # Emergency Contact Name: Emergency Contact Phone # Date Of Birth Age: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Height: Weight: Occupation: Marital Status Single Married Widowed Divorced Please check all the answers and fill in the blanks where appropriate. Reason(s) for appointment: When did your condition begin? Have you ever had similar problems? Yes No Have you had X-rays, MRI or other tests for this condition? Yes No Which tests, when? Is this a work related injury? Yes No Has your employer been notified? Yes No Is this a Motor Vehicle Accident (MVA)? Yes No On what date did the accident occur? Can you perform daily home activities? Yes Yes, but only with help Not at all Can you perform your daily work activities? All activities Only some activities Not at all Describe your stress level None Mild Moderate High Do you exercise? Daily Occasionally Not at all What kinds of exercise do you do? List all previous surgeries, illnesses, injuries (including MVA): Have you had previous chiropractic care? Yes No Dr. Date: Family doctor name: List all medications, over the counter and prescriptions, supplements, vitamins, herbal supports, aspirin, etc: Health History Questionnaire Patient Name: Date: Have you ever been diagnosed or told you to have any of the following? 1. High Blood Pressure Yes No 2. Hardening of the arteries (arteriosclerosis) Yes No 3. Diabetes Yes No 4. Tuberculosis Yes No 5. Cancer Yes No If Yes, Where? Heart or blood diseases Yes No 7. Bone spurs on the neck bones (cervical sprain) Yes No 8. Whiplash injury (flexion-extension injury, cervical sprain) Yes No 9. Have you or any of your relatives suffered a stroke? Yes No 10. Were you ever a smoker? Yes No From To 11. Do you take medication on a regular basis? Yes No 12. Visual disturbances (blurring, loss, double vision) Yes No 13. Hearing disturbances (loss, ringing, other noise) Yes No 14. Slurred speech or other speech problems Yes No 15. Difficulty swallowing Yes No 16. Dizziness Yes No 17. Loss of consciousness, even momentary blackouts Yes No 18. Numbness, loss of sensation, loss of strength or weakness in the face, fingers, hands, arms, legs, or any other parts of the body? Yes No 19. Sudden collapse without loss of consciousness Yes No Indicate the severity of your pain (0 - No Pain | 10 - Extreme Pain) 1 2 3 4 5 6 7 8 9 10 Missed appointments are an inconvenience not only to us but also for other patients who may have wanted your appointment time. If you do not call to inform us that you cannot keep your scheduled appointment you will be billed. I understand that my Supplemental Health Care coverage for chiropractic care represents only a portion of the Doctor's fee and that I am personally responsible for the balance of that fee. Date: Patient Consent I agree to the terms
