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

Month Day 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?

constant comes and goes worse at night worse in morning getting better getting worse occasional
What does it feel like?

dull sharp burning tingling throbbing tight pins/needles referring/radiating
Check all that applies:

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

work sleep family time sitting walking hobbies

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?

constant comes and goes worse at night worse in morning getting better getting worse occasional
What does it feel like?

dull sharp burning tingling throbbing tight pins/needles referring/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?

No Yes
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 cholesterol diabetes high blood pressure cancer osteoporosis arthritis
I have had these past traumas:

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

Low Back Pain Pain Between Shoulders/Mid-back pain Neck pain Headaches/Migraines Tiredness/Fatigue Tight Muscles Tension in Shoulders/Mid-back Fibromyalgia Stress Digestive Issues Numbness/Tingling in Arms/Hands Numbness/Tingling in Legs/Feet Dizziness Vertigo Ringing in Ears Frequent Colds Thyroid Problems Depression Anxiety Asthma/Allergies Menstrual Cramps Mood Swings Sexual Dysfunction Heartburn Walking/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?

Yes No Unsure I'm frustrated because I've tried so many things that haven't worked
Lifestyle/Habits
Check all that apply:

I consume alcohol I consume soft drinks/sugary foods I sleep poorly I consume coffee I exercise regularly I eat healthy I drink plenty of water I sleep well I have a lot of energy I am always tired
For Women Only
Are you pregnant? Due date?
Any contraception?
Severe cramping with menstrual period? PMS?
Date of last menstrual period:

Month Day 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.
Print Name:
Signature:

Clear
Date

Month Day 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