Date of Birth
Number of Children
Work Phone #
Cell/home Phone #
HOW DID YOU HEAR ABOUT OUR OFFICE?
Please Check One:
Health Care Professional (eg. Physician, Physiotherapist, Massage Therapist etc.)
Please let us know who we can thank for referring you to our office:
OUR HEALTH GOALS:
Where is/are the problem(s) (if visits is not just for overall health)? Please use the lines below to explain.
How long has this been going on?
When did this incident occur?
Is this related to:
Do you have:
Is your pain:
Are your symptoms affected by:
Do your symptoms interfere with:
Hobbies and Leisure Activities
On a scale of 1-10 (1 = least, 10 = most), please rate the severity of your symptoms
1 is Least, 10 is Worst
Do you get headaches?
Are you receiving care from any other health professionals?
If Yes, please name them and their speciality:
GENERAL HEALTH HISTORY
Past injuries can affect present health.
Please check all that apply:
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 have any other health concerns we should know about?
If Yes, please describe:
If you had a magic wand, what 3 health conditions or issues would you like to improve?
Is there anything else that you would like us to know about you?
If Yes, please tell us:
Thank you so much for filling out the Low-Level Laser & PEMF New Patient Health Questionnaire. We look forward to helping you with your specific health concerns and overall well-being!
The Team at Santé Chiropractic and Wellness Centre
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