Handley Chiropractic Clinic Patient Entrance Form (Page 2 of 5) in pdf

HANDLEY CHIROPRACTIC CLINIC

Dr. Leonard Handley, D.C.

PATIENT ENTRANCE FORM

727 Gardiners Road | Kingston, ON K7M 3Y5

(613) 384-1008 ●

Please mark the areas on the appropriate diagram(s) below where you feel the described sensations, using the appropriate symbols.

Be sure to include ALL of your affected areas (even if they’re not why you’ve come today!):

• • • • •

Pins & Needles:

Burning:

x x x x x

Aching:

Stabbing:

/ / / / /

0 0 0 0 0

Numbness:

* * * * *

• • • • •

x x x x x

0 0 0 0 0

/ / / / /

* * * * *

x x x x x

0 0 0 0 0

• • • • •

/ / / / /

* * * * *

Have you ever had any of the following?

(please check)



aneurysm

stroke(s)

epilepsy

diabetes

arthritis

osteoporosis

cancer

polio

pleurisy



hepatitis

“nerves”

fatigue

allergies

asthma

pneumonia

psoriasis

HIV

venereal disease



sleeping difficulty .........................................................................................................................................................................................................



heart conditions ...........................................................................................................................................................................................................



sinus conditions ............................................................................................................................................................................................................



respiratory conditions ...................................................................................................................................................................................................

Childhood conditions experienced

(please check)



measles

stroke(s)

chicken pox

whooping cough

scarlet fever

diphtheria

rheumatic fever



typhoid fever