Welcome to our Wellness Family
VITA CHIROPRACTIC AND WELLNESS CENTRE – 1060 LORNE ST UNIT 6– SUDBURY, ON – P3C 4R9 (705) 586-8482 (VITA)
Your Wellness History
Date: ______
CONTACT INFORMATION
Name: ______DOB: ______
Male ___ Female ___
Address: ______City: ______Prov. ____
Postal Code ______
Home #: ( ) ______Cell #: ( ) ______
Single ___ Married ___ Partnered ___ Divorced ___ Separated ___
Email Address: ______
Occupation: ______Employer Name: ______
Work #: ( ) ______Can we call you at work? ______
Emergency Contact: ______Phone #: ______
Family Doctor: ______Phone #: ______
Have you ever been adjusted by a chiropractor? Yes ____ No ____
Chiropractors Name: ______Approximate date of last visit: ______
Number of Children: ______
Has your family received chiropractic care? ______
How did you hear about us? ______
Would you like to receive our weekly wellness newsletter? Yes ____ No ____
PATIENT NAME: ______
Your Wellness History – Page 2
Please Rate Your Health and Wellness
Place an ‘X’ where you believe your current level of wellness is.
Place an ‘O’ where you would like your wellness to be.
YOUR HEALTH PROFILE
What brings you to our wellness clinic today?
Please briefly describe your reason for visiting. (If you are here for a wellness assessment, please skip to the General History section):______
______
Does this interfere with your: leisure ___ work ___ sleep ___ sports ___ other _____
Please explain:
______
Since the problem started is it: the same ___ improving ___ more severe ___
What, if anything, makes the problem worse? ______
What, if anything, makes the problem feel better? (i.e. heat, ice, stretching, etc.)
______
GENERAL HISTORY
Please list all medications you are taking, and why; (Prescription and non-prescription)
______
Have you had any surgeries and/or hospitalizations? ____ Yes ____ No
If yes, please describe and indicate dates: ______
PATIENT NAME: ______
Your Wellness History – Page 3
GENERAL HISTORY Continued
Have you ever had any work related injuries? ____ Yes ____ No
If yes, please indicate dates and severity: ______
______
Have you ever been in a motor vehicle accident? ____ Yes ____ No
If yes, please indicate dates and severity:______
______
Have you broken any bones? ____ Yes ____ No
If yes, briefly explain and provide dates:______
______
Have you ever had any slips, falls, or accidents? ____ Yes ____ No
If yes, please indicate dates and severity: ______
YOUR WELLNESS GOALS
On a scale of 1 to 10 (1 = none, 10 = extreme), please rate your level of stress:
Occupational: _____ Personal: ______
On a scale of Poor, Good, Or Excellent, please describe your habits and conditions as it relates to:
Eating: ______Exercise:______Sleep: ______General Health: ______Wellness Lifestyle: ______
How often do you: Drink coffee ______Drink alcohol ______Smoke ______
How many hours a day do you sit ______
Please check all that are relevant.
Do you:Would you like to know more about:
Water – Drink ½ your body weight in Proper nutrition and meal planning
ounces Proper exercise routines and
Exercise regularly techniques
Take vitamins or supplements How to deal with lifestyle stress