Adult Form - Chiropractic On Eagle
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1
2NEW PATIENT HEALTH HISTORY FORM
Patient Data
Name:
M / F Address:
City:
Province:
Postal Code:
Phone: H:
W:
Ext:
C:
Birth Date:
Age:
Spouse:
Kids? Y
N Names and Ages:
Your Occupation:
Family Physician:
Previous Chiropractor:
Reason for discontinuing?
Whom shall we thank for referring you to our office?
Do you have health insurance?
Name of company:
Plan number:
* Your Best Email Address:
*Your email address will NOT be shared with anyone and will be used to email you your financial statements and for occasional
office announcements. We are moving towards an entirely paperless office, so please help us by providing your email address.
Thank you!
Current Health Profile
Your Main Complaint:
Secondary Complaints:
How long have you suffered with this problem?
What makes this problem worse?
Better?
What is the pattern of this problem (circle)? constant
occasional
comes and goes
worsening
How did it start?
Do you experience pain at night? Y
N Night sweats? Y
N Unexplained weight loss? Y N
If you are experiencing pain, is it (circle): dull
sharp
pins/needles
burning
tight
throbbing
What does it interfere with (circle): work
sleep
walking/standing
sitting
hobbies/leisure
family
Names of other doctors seen for this problem:
Please circle the intensity of your problem:
(no pain/feeling great) 1 ------ 2 ----- 3 ----- 4 ----- 5 ----- 6 ----- 7 ----- 8 ----- 9 ----- 10 (worst pain imaginable)
Health History
Do you smoke? Y
N
How many Years?
# Packs/day?
Are you on any type of medication? Y
N
Please list:
Do you take any supplements? Y
N
Please list:
Any surgeries?
My past health history has been (circle):
poor
ok
good
very good
excellent
I suffer from (circle): high cholesterol
diabetes
cancer
osteoporosis
arthritis
high blood pressure
Other:
Have you been involved in an auto accident? Y
N
Date of accident:
Please think of past traumas in your life (minor car accidents, falls, traumatic birth, sports injury, falls as a child,
etc). It is important that you complete this as best as you can. List your top 3:
1.
2.
3.
Chiropractic On Eagle, Dr. J. Saunders
407 Eagle Street, Newmarket, ON L3Y1K5
905.953.1028
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