ADULT NEW PATIENT HEALTH HISTORY FORM

ADULT NEW PATIENT HEALTH HISTORY FORM

Welcome! Please complete form in full.
Patient Data
Name

First Name Last Name
Date of Birth

MonthDay Year
Date
Age
Gender
Address

Street Address

Street Address Line 2

City Province

Postal Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Business Phone Number

Area Code Phone Number
Your Best Email
example@example.com
Spouse &/or Kids?
Names
Your Occupation?
Family Physician
Previous Chiropractor?
Why did you discontinue?
moved, got better, no results, etc...
Who should we thank for referring you to our office?
Family member or friend? Website? Another Health Provider? Google? YouTube? Facebook? Instagram? Other?
Current Health Profile
Your Main Complaint:
How long have you suffered with this?
What makes it better?
What makes it worse?
How did it start?
What is the pattern?

constantcomes and goesworse at nightworse in morninggetting bettergetting worseoccasional
What does it feel like?

dullsharpburningtinglingthrobbingtightpins/needlesreferring/radiating
Check all that applies:

I have pain at nightI get night sweatsI have had unexplained weight lossI have pain at night, but only when I move (e.g. roll over)
My problem (s) interferes with:

worksleepfamily timesittingwalkinghobbies

Please select the intensity of your problem (0=feeling great; 10=worst imaginable)

	0	1	2	3	4	5	6	7	8	9	10

0 is Feeling Great, 10 is Worst Imaginable

Who else have you seen for your problem?
Any secondary complaints?
How long have you suffered with this secondary complaint?
What makes it better?
What makes it worse?
What is the pattern?

constantcomes and goesworse at nightworse in morninggetting bettergetting worseoccasional
What does it feel like?

dullsharpburningtinglingthrobbingtightpins/needlesreferring/radiating

Please select the intensity of your secondary problem (0=feeling great; 10=worst imaginable)

	0	1	2	3	4	5	6	7	8	9	10

0 is Feeling Great, 10 is Worst Imaginable

Health History
Do you smoke?

NoYes
If you smoke, for how long and how many packs/day?
Please list any medications you are currently taking.
Please list any supplements you are taking.
Please list any past surgeries.
Any past motor vehicle accidents? Date?
My past health history has been:
select from menu
I have or have suffered from:

high cholesteroldiabeteshigh blood pressurecancerosteoporosisarthritis
I have had these past traumas:

fall (s) (tripping, slipping, etc...)sports injury (s)car accident (s)lots of desk/PC worksleep on stomach
Please check all that apply:

Low Back PainPain Between Shoulders/Mid-back painNeck painHeadaches/MigrainesTiredness/FatigueTight MusclesTension in Shoulders/Mid-backFibromyalgiaStressDigestive IssuesNumbness/Tingling in Arms/HandsNumbness/Tingling in Legs/FeetDizzinessVertigoRinging in EarsFrequent ColdsThyroid ProblemsDepressionAnxietyAsthma/AllergiesMenstrual CrampsMood SwingsSexual DysfunctionHeartburnWalking/Balance Problems
What can't you do right now that is preventing you from fully enjoying your life?
What are your short and long-term health goals?
Rate the importance of correcting your problem (0=not important, 10=most important
pick number between 0 and 10
Do you believe you can get better?

YesNoUnsureI'm frustrated because I've tried so many things that haven't worked
Lifestyle/Habits
Check all that apply:

I consume alcoholI consume soft drinks/sugary foodsI sleep poorlyI consume coffeeI exercise regularlyI eat healthyI drink plenty of waterI sleep wellI have a lot of energyI am always tired
For Women Only
Are you pregnant? Due date?
Any contraception?
Severe cramping with menstrual period? PMS?
Date of last menstrual period:

MonthDay Year
Date
Additional Information
Is there any other information you would like us to know?
COVID-19 SCREENING
I do NOT have a fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?

I confirm
I have not had any close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?

I confirm
I do not have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

I confirm
I do not have two (2) or more of the following symptoms: sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smell, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain, or nausea/vomiting?

I confirm
If you are over 65 years of age, I am not experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions?The patient once again confirmed the above requirements prior to receiving treatment.

I confirm
I give my consent to have the doctor(s) perform an exam and take any x-rays that are deemed appropriate to better understand my problem and monitor my progress. You will recieve communications, statements, etc. from us via email and/or text message that you can unsubscribe to at any time.
Print Name:
Signature:

Clear
Date

MonthDay Year
Date
Chiropractic on Eagle, Dr. Jon Saunders 407 Eagle Street, Newmarket, ON L3Y1K5 905.953.1028 www.chirofirst.ca
Should be Empty:

ADULT NEW PATIENT HEALTH HISTORY FORM

Patient Data

Current Health Profile

Health History

Lifestyle/Habits

For Women Only

Additional Information