DR.DATE:

Full Name:Name of Preference:

Address:City:Prov:Postal Code:

Telephone: Res.Bus.Cell:

Birthdate:Age:Alberta Health Care #:

Occupation:E-mail address:

Marital Status: single__ cohabiting__ married__ divorced__ widowed__ separated__

Name of Spouse:Names of children and ages:

Name of your medical doctor if you have one?______

Whom can we thank for referring you? ______

EXISTING SYMPTOMS

If you have a specific chief complaint(s), please use the symbols indicated below to describe it. Include all affected areas. If the pain travels to another area, please mark it on the diagram.

Ache > > > >

Numbness = = = =

Pins and Needles o o o o

Burning x x x x

Stabbing / / / /

Throbbing ~ ~ ~ ~

How long have you been living this way?

Days___ Weeks___ Months ___ Years___

Did your complaint(s) come on: Suddenly?___ Gradually?___

Is this complaint(s) getting: Better?__ Same?___ Worse?___

Is the condition worse in the: AM?___ PM?___ No change?____

Is the problem: Constant?___ Intermittent?___ Worse with movement?___

Condition is worse with: Right rotation?___ Left rotation?___

Bending: Forward?___ Backward?___ Sideways?___

The condition interferes with my: Sleep?___ Work?___ Family Life?___ Exercise?___

What activities aggravate your condition/pain? ______

______

What (if anything) relieves your condition/pain? ______

On a scale between 1 (no pain) and 10 (intense pain), place an X where you are currently at:

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What have you done for the complaint(s) so far?

Exercise___ Prescription drugs___ Physiotherapy___ Massage___ Other ______

Is this a Worker’s Compensation Case? Yes___ No___ If Yes, the date of injury?______

Did your complaint(s) arise from a Motor Vehicle Accident? Yes___ No___

If Yes, what was the date of injury?______

Have you have seen a chiropractor before? Yes___ No___

If Yes, who did you see and when was your last visit? ______

Have you had any of the following in the last 2 years? X-rays___ CT Scans___ MRIs___

If Yes, which area(s) of the body was done? ______At which facility?______

SYSTEM REVIEW

Do you currently suffer from or have a history of suffering from any of the following symptoms?

Do you experience any tingling or numbness in your:

Arms? ___ Hands? ___ Chest? ___ Buttocks/hips? ___ Legs? ___ Feet? ___

Is there a family history of:

Heart disease? ___ Stroke? ___ Cancer? ___ Diabetes? ___ Other? ___

Please list any medications that you are currently on or give us a list we can copy: ______

______

List any surgeries you have had and include when: ______

______

Is there a chance you could be pregnant? Yes ___ No ___

LIFESTYLE EVENTS AND HABITS

Stress of any type has a profound impact on our health and well-being over time.

  1. PHYSICAL STRESS

Briefly describe any notable injuries, slips or falls (example: horseback riding, tobogganing, falls down stairs, slips on ice). Try to remember to include how old you were at the time, as childhood injuries left uncorrected can lead to problems later in life.

______

List any motor vehicle accident injuries: include date if known and describe collision (rear-end, roll-over, seatbelt, airbags?)

______

______

Sports injuries (head traumas, concussions, broken bones): ______

______

Do you spend any significant time:

Sitting? ___ Bending forward? ___ Twisting? ___ Lifting? ___ Driving? ___ Computer? ___

If yes to sitting/driving/computer, how many hours per day do you spend at these activities? ______

Do you exercise on a regular basis? Yes___ No ___ How many times per week? ______

Do you sleep on your: Back? ___ Side? ___ Stomach? ___ Age of mattress? ______

Rate your posture out of 10 (1 – poor 10 – excellent):

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Rate the amount of physical stress that your body goes through on a daily basis:

(1 – no physical stress 5 – moderate physical stress 10 – heavy stress load)

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  1. CHEMICAL STRESS

Do you smoke, if so, how much and how long? ______

Drink alcohol? Daily? ___ Week-ends? ___ Socially? ___

My caffeine intake is: Low? ___ Moderate? ___ High? ___

I eat processed foods: Rarely? ___ Occasionally? ___ Often? ___

I use over the counter drugs (Aspirin, etc): Rarely? ___ Occasionally? ___ Often? ___

  1. EMOTIONAL STRESS

My stresses include: Work? ___ Home? ___School? ___ Finances? ___ Family? ___

Relationships? ___ Health problems? ___ Other? ______

Rate your stress level (1 – rarely stressed 10 – always stressed)

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