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?

Other
What does it feel like?

Other
Check all that applies:

Other
My problem (s) interferes most with:

Other

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?

Other
What does it feel like?

Other

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?
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:

Other
I have had these past stresses/traumas:

Other
Please check all that apply:

Other
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?
Lifestyle/Habits
Check all that apply:

Other
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:
Date

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