• PERSONAL & CONTACT INFORMATION
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
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  • GENERAL HEALTH HISTORY
  • Do you have any known allergies or suspected food intolerances?
  • Have you ever been treated for:
  • HEALTHY LIVING AND WELLNESS SELF-ASSESSMENT
  • Our centre is a wellness-oriented chiropractic practice for health-conscious, wellness-minded individuals and their families. We strive to improve the overall health and wellbeing of our patients, and take a proactive approach to health care so that our patients may live healthier, happier lives. To better understand your health and wellbeing, it is important that we review your lifestyle habits. Please score yourself according to how well you match the following statements: 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always
  • Your Fitness
    Rows
  • Your Nutrition
    Rows
  • Your Mind
    Rows
  • DIETARY HABITS
  • Please check if you eat, drink or use any of the following (even occasionally):
  • Do you consider yourself?
  • How often do you consume dairy products?
  • Do you avoid certain foods?

  • Thank you for filling out the Registered Holistic Nutrition Health Questionnaire. We look forward to helping you with your Health!

    The Santé Chiropractic and Wellness Centre
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