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  • CHILD NEW PATIENT HEALTH HISTORY FORM

    Please complete form in full. Parent signature required for those under 18 years of age.
  • Patient Data

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  • Current Health Profile



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  • Health History




  • Lifestyle/Habits


  • COVID-19 SCREENING

    Please confirm that you DO NOT:

    1) Presenting with fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?


    2) Have not had any close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?


    3) Do not have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?


    4) 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?


    5) If you are over 65 years of age, are you experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions?

  • 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.  Also, I consent to use of my email for office announcements and/or emailing/texting reminders for my visits.

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    Pick a Date
  • Chiropractic on Eagle, Dr. Jon Saunders    407 Eagle Street, Newmarket, ON L3Y1K5   905.953.1028   www.chirofirst.ca

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