Chiropatic Intake Form printable pdf download

Chiropatic Intake Form

Welcome to Adjust Your Health

Sports & Family Health Centre

In order for the Doctors and/or Practitioners to provide you with the best possible care the following

confidential information must be completed.

Patients Name: __________________________________________

Date: ______________

Last

First

Address: ____________________________________________________________________

City

Postal Code

Home Phone #:_________________________

Date of Birth: ___________________

Work Phone #:__________________________

Sex: Female Male

Alberta Health Care #_____________________

Marital Status: S M D W

Occupation: _____________________________

E-Mail:_________________________

Employer: ______________________________

Referred By: ____________________

General Pain Disability Index

Use the letters to indicate the type and location of your sensations right now.

A (ache)

B(burning)

N(numbness) P(pins & needles)

S(stabbing)

O(other)

Chiropatic Intake Form