Personal Information
First Name
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Last Name
*
Date of Birth
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Month
-
Day
Year
Date
Age
Biological Sex
Female
Male
Number of Children
Family Doctor
Occupation
Contact Information
Address
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City
*
Postal Code
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Cell or Home Phone #
*
-
Area Code
Phone Number
Work Phone #
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Area Code
Phone Number
E-Mail
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How did you hear about our clinic? (Check one):
Family Member
Friend or Co-Worker
Health Care Professional (eg. Physician, Physiotherapist, Massage Therapist, etc.)
Internet Search
Social Media
Other
Please let us know who we can thank for referring you to our office:
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What Brings You To The Clinic?
What area(s) of your body are bothering you the most? (Check all that apply)
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Back Pain
Neck Pain
Headaches
Shoulder, Elbow, or Wrist Pain
Knee, Hip, or Ankle Pain
Fatigue
Digestive Issues
Cardiovascular / Blood Pressure Issues
Blood Sugar Issues / Diabetes
Hormone Imbalance
Other
Symptom History
How long has this problem been going on?
Just started
A few days
A few weeks
A few months
A year or longer
How often are your symptoms present?
Rare
Intermittent
Occasional but daily
Frequent (most days)
Constant
How would you describe the intensity?
Mild
Annoying
Moderate
Getting worse
Intense
Do your symptoms interfere with daily activities?
No
Occasionally
Some activities are limited
Most activities are limited
Extremely limited
Previous Care and Treatment
Who have you seen for this concern or goal? (Please check all that apply)
Primary Care Physician
Physiotherapist
Massage Therapist
Medical Specialist
Self-treated
Have not sought care yet
Other
What was the outcome?
No improvement
Slight or temporary improvement
~25% improvement
~50% improvement
~75% improvement
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Key Health Context
(This helps us understand how your body is functioning overall)
Sleep
Sleep well (7–8 hours)
Sleep OK (6–7 hours)
Trouble falling asleep
Wake during the night
Poor sleep/sleep deprived
Energy
Great energy all day
Good energy, could improve
Afternoon energy dips
Energy fluctuates, often low
Low energy/fatigue, rely on stimulants
Immunity
Rarely sick
Occasionally sick, recover quickly
Get sick when stressed or run down
Often sick, slow recovery
Catch most illnesses
Mind & Emotions
No concerns
Mild mood changes
Brain fog and/or anxiety
Memory or focus issues
Frequent mood or emotional changes
Weight
At ideal weight
About 10 lbs over/under
Hard to maintain weight
Very hard to lose weight
Significantly overweight
Lifestyle Habits
(Risk factors & recovery capacity)
Exercise
Daily
4–5x per week
3x per week
1–2x per week
Rarely / sedentary
Hydration
8–10 glasses of water per day
6–7 glasses of water per day
4–5 glasses of water per day
1–3 glasses of water per day
Mostly coffee or tea
Nutrition
80–100% whole foods
60–80% whole foods
About 50% whole foods
Minimal whole foods
Frequent cravings / processed foods
General Health History
(Past injuries can affect current health)
Please check all that apply:
Falls/Accidents
Sports Injuries
Head Injuries/Concussions
Broken Bones
Knocked Unconscious
Car Accidents
Surgery
Joint Replacement
Stroke
Pacemaker
If you answered Yes to any of the above, please describe:
Please list any medications you are taking and the reason for the medication:
Please list any vitamins or supplements that you are taking:
Do you wear orthotics or heal lifts?
Yes
No
Have you ever had X-rays taken of your:
Neck
Back
Neither
If Yes, please tell us where and when these X-rays were taken:
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Nervous System Review
Your spine protects your nervous system, which helps regulate and coordinate every function in your body. Different areas of the spine are connected to different regions and systems. Checking these symptoms helps us understand how your nervous system may be influencing your overall health.
Cervical Nerves
Eye Strain
Red Eyes
Vision Problems
Weight Gain
Ear Infection
Ringing in the Ears
Ear Discharge
Crave Sweets
Hearing Loss
Sinusitis
Runny Nose
Memory Loss
Canker Sores
Sore Throat
Sore Gums
Nightmares
Inner Ear Problems
Speech Difficulty
Cavities
Tonsillitis
Hoarse/Laryngitis
Headaches
Migraines
Emotional Instability
Chronic Fatigue
Dizziness
Anxiety
Insomnia
Upper Thoracic Nerves
Asthma
Chest Pain
Pain over Heart
Difficulty Breathing
Persistent Cough
Bronchitis
Coughing Phlegm
Coughing Blood
Rapid Heartbeat
High Blood Pressure
Heart Problems
Numbness in Hands
Lung Problems
Fluid Retention
Pleurisy
Difficulty Swallowing
Nausea
Gall Bladder Attacks
Bloating
Intolerance to Fatty Foods
Mid Thoracic Nerves
Poor Appetite
Excessive Hunger
Gastric Ulcer
Crave Sweets
Difficulty Swallowing
Excessive Thirst
Liver Trouble
Vomiting Food
Abdominal Pain
Diarrhea
Immune Deficiencies
Constipation
Pancreatitis
Black Stool
Hypoglycemia
Lower Thoracic Nerves
Allergies
Sneezing
Overwhelmed
Digestive Complaints after Eating
Appendix Problems
Bladder Problems
Kidney Problems
Testicular or Ovarian Problems
Bladder Infections
Swollen Ankles
Dizziness upon Standing
Lumbar Nerves
Bladder Trouble
IBS
Bad Breath
Flatulence
Bowel Problems
Painful Urination
Infertility
Dark Circles under Eyes
Impotence
Dysmenorrhea
Prostate Problems
Reproductive Disorders
Female Problems
Hemorrhoids
Varicose Veins
Hormonal Imbalances
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Chiropractic Care
Your primary reason for seeking chiropractic care is:
To address a specific health concern or symptom
To support overall health, function, and resilience
A combination of both
Have you received chiropractic care in the past?
Yes
No
If yes, how would you describe your experience?
Very helpful / productive
Somewhat helpful
Not helpful
Unsure / mixed experience
If you stopped chiropractic care in the past, what was the main reason? (Check all that apply)
My concern improved / I felt better
I did not notice enough improvement
Scheduling or time constraints
Cost or insurance coverage
I moved or changed providers
I was unsure of the plan or next steps
Other
Your Health Goals
We want to make sure we focus on what matters most to you.
If you had a magic wand, what 3 health issues would you most like to improve?
Is there anything else that you would like us to know about you?
Yes
No
If Yes, please tell us:
Patient Communication Preferences
Please select your preferred method of communication for appointment reminders, confirmations, missed visits, and rescheduling:
Choose One:
Email
Text Message
By choosing “Text message,” you give consent to receive appointment-related texts from our clinic, in accordance with Canadian Anti-Spam Legislation (CASL).
THANK YOU FOR FILLING OUT OUR CHIROPRACTIC NEW PATIENT HEALTH QUESTIONNAIRE!
We look forward to helping you with your current health concerns and overall well-being.
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