Handley Chiropractic Clinic Patient Entrance Form (Page 4 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 ●

PAST MEDICAL HISTORY,

continued

*1 unit =

1 glass of wine

1 bottle of beer

HABITS OF LIFESTYLE:

1 shot of liquor



Do you smoke?

YES

NO ............................... packs/week

Do you consume alcohol?

YES

NO ................................. units*/week



Do you exercise?

YES

NO ............................... times/week

Activities ..................................................................................................................



Rate your sleep in hours per night:

4-6

6-8

8-10

10-12

>12

Do you wake rested?:

YES



Rate your appetite:

Poor

Fair

Medium

Good

Excellent



Rate your diet:

Poor

Fair

Medium

Good

Excellent



Meals you eat regularly:

Breakfast

Lunch

Dinner



Meals you eat per day:

none

1 meal

2 meals

3 meals

4 meals

more than 4 meals

Date of last dental examination: ..............................................................

List all falls and/or accidents: .............................................................................................................................................................................................................

.........................................................................................................................................................................................................................................................

List all surgeries and/or operations:....................................................................................................................................................................................................

List surgeries that have been recommended, but not yet performed: .................................................................................................................................................



Have you ever been knocked unconscious?

YES

UNSURE

: ................................................................................................

If YES, for how long?



Have you previously been hospitalized?

YES

NO For what?: ...........................................................................................................................

List any medications and/or drugs you are currently taking: ...............................................................................................................................................................



Do you take vitamins and/or minerals?:

YES

NO List types: ...........................................................................................................................



Are there any family health conditions and/or problems that we should be aware of?:

YES

UNSURE If YES, please list:

Page 4 of 5

C:/My Documents/CLINIC FILES/CLINIC Forms/HANDLEY Patient Entrance.doc [last updated on 11-NOV-2010]