Confidential Patient Information
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3801 River Rd. W.
Wasaga Beach, ON. L9Z 2N7
Phone – (705) 422-1221
Fax – (705) 422-1228
CONFIDENTIAL PATIENT INFORMATION
Personal Information
Full name:
Date:
Address:
Street
City
Province
Postal Code:
Home phone:
Work phone:
Cell phone:
Email address:
Age:
Date of birth:
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No. of children:
Pregnant?
Yes
No
Spouse/guardian name:
Marital status:
M
S
W
D
Occupation:
Emergency contact name/ relation to you:
Emergency contact phone:
Family Doctor:
Address:
Phone #:
You will be sent a series of email on how to improve your care. Please check box if you do not want these emails sent
How did you hear about us? __________________
________________________________________________________
*Addressing What Brought You Into This Office:
If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.
Health Concerns
Please list your health concerns
Rate of severity
When did this
If you had this
Did the problem
% of the time
according to their severity
episode start?
condition
begin with an
pain is
1 = mild
before, when?
injury?
present
10 = worst
imaginable
1.
2.
3.
Other doctors/therapist you have seen for this condition:
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“Limited Scope” Chiropractor (focuses mainly on neck and back pain)
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“Wellness” Chiropractor (focuses on health and well-being as well as underlying cause of pain and health concerns)
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Medical Doctor
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Other (please describe)
Is this condition interfering with any of the following:
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□
□
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Work
Sleep
Daily routine
Sports/exercise
Other
(please explain):
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