Form - Dr. Jordan Bennett

Contact Information

Name*

First Last

Date*

Home Address*

Street Address Address Line 2 City Province Postal Code

Gender*

Male
Female
Prefer not to say

Home Phone*

Business Phone

Cell

Email*

Occupation

Employer

Physician Contact Information

Family Physician

Phone

Address

Street Address Address Line 2 City Province Postal Code

Reason For Visit

How did hear of our clinic?*

Nature of Complaint?*

Does this complaint interfere with:*

Sleep
Daily Routines
Work
Other

Describe:

Have you been treated for this complaint before?*

Yes
No

Please specify your treatment:

Are you currently taking any medications or natural supplements?*

Yes
No

Please specify drug and/or supplements:

Have you previously received chiropractic care/physiotherapy/massage therapy/acupuncture?*

Yes
No

Please specify:

Medical History Details

Have you ever had problems in the following body systems? (Please specify what the problem was and when it occurred)

ENDOCRINE SYSTEM*

(Diabetes, Thyroid, Chushing's, etc.)

Yes
No

Please specify:

GENITOURINARY SYSTEM*

(Kidney/bladder infections, Prostate, Painful/frequent urination, etc.)

Yes
No

Please specify:

CARDIOVASCULAR SYSTEM*

(High or low blood pressure, Stroke, Swollen ankles, Heart attack, etc.)

Yes
No

Please specify:

IMMUNE & LYMPHATIC SYSTEM*

(Lupus, Allergies, Chronic Fatigue Syndrome, etc.)

Yes
No

Please specify:

MUSCULOSKELETAL SYSTEM*

(Muscle/joint/bone disease such as Arthritis/gout, Extremity problems, Scoliosis, Postural problems, Fibromyalgia, etc.)

Yes
No

Please specify:

DIGESTIVE SYSTEM*

(Belching/gas, Constipation/diarrhea, Gall stone, Nausea/vomiting, etc.)

Yes
No

Please specify:

RESPIRATORY SYSTEM*

(Lung disease, Asthma, Sinusitis, etc.)

Yes
No

Please specify:

NERVOUS SYSTEM*

(Epilepsy, Numbness/tingling, Weakness, Tremors, Multiple Sclerosis, etc.)

Yes
No

Please specify:

SENSORY SYSTEM*

(Problems with balance, Dizziness, Ringing in ears, Changes ini vision, Smell, Hearing, Taste, etc.)

Yes
No

Please specify:

OTHER*

(Cancer, Migraines, Anemia, Unexplained pain or weight changes, Skin conditions, etc.)

Yes
No

Please specify:

Previous x-rays/MRI/CT/Bone Scan?*

Yes
No

Please specify:

Any falls, accidents, injuries?*

Yes
No

Please specify:

Any surgery?*

Yes
No

Please specify:

Is there a family history of any disease?*

(Stroke, Cancer, High blood pressure, Heart disease, Diabetes, Arthritis, etc.)

Yes
No

Please specify:

Signature

Signature*

Date*

Confidential Patient Information and Medical History

Contact Information

Physician Contact Information

Reason For Visit

Medical History Details

Signature