ADULT NEW PATIENT HEALTH HISTORY FORM

ADULT NEW PATIENT HEALTH HISTORY FORM

Welcome! Please complete form in full.
Patient Data
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Gender
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Business Phone Number

Area CodePhone 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/friend? Another Health Provider or Doctor? Google? YouTube? Social Media?
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 worseoccasionalOther
What does it feel like?

dullsharpburningtinglingthrobbingtightpins/needlesreferring/radiatingOther
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)Other
My problem (s) interferes most with:*

worksleepfamily timesittingwalkinghobbiesOther

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?
What else have you tried to get rid of your problem? (physio, massage, acupuncture, etc...)
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 worseoccasionalOther
What does it feel like?

dullsharpburningtinglingthrobbingtightpins/needlesreferring/radiatingOther

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 pressurecancerosteoporosisarthritisOther
I have had these past stresses/traumas:

fall (s) (tripping, slipping, etc...)sports injury (s)car accident (s)lots of desk/PC worksleep on stomachOther
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 ProblemsOther
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?*
What are your favourite hobbies?*
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 tiredOther
For Women Only
Are you pregnant? Due date?
Any contraception?
Severe cramping with menstrual period? PMS?
Date of last menstrual period:

MonthDayYear
Date
Additional Information
Is there any other information you would like us to know?
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 receive communications, statements, etc. from us via email and/or text message that you can unsubscribe to at any time.
Print Name:
Signature:

Clear
Date

MonthDayYear
Date
Chiropractic on Eagle, Dr. Jon Saunders 407 Eagle Street, Newmarket, ON L3Y1K5 905.953.1028 www.chirofirst.ca
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ADULT NEW PATIENT HEALTH HISTORY FORM

Patient Data

Current Health Profile

Health History

Lifestyle/Habits

For Women Only

Additional Information