Form - Dr. Jordan Bennett

121 Main Street N., Markham Ont L3P 1Y2 905-471-1336 info@drjordanbennett.com

Home
About
Chiropractic
Services
Resources
Contact

Select Page

Confidential Patient Information and Medical History

Contact Information
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
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*
Date Format: MM slash DD slash YYYY

Designed by Elegant Themes | Powered by WordPress

A message from Dr. Bennet

DUE TO THE COVID-19 PANDEMIC OUR CLINIC IS NOW CLOSED.

PLEASE CHECK OUR WEBSITE OR FACEBOOK PAGE REGULARLY FOR CURRENT UPDATES.

WE APPRECIATE YOUR PATIENCE DURING THIS DIFFICULT TIME.

Jordan Bennett B. Kin., DC.