Confidential Patient Information and Medical History Contact InformationName* First Last Date* Date Format: MM slash DD slash YYYY Home Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Gender*MaleFemalePrefer not to sayHome Phone*Business PhoneCellEmail* OccupationEmployerPhysician Contact InformationFamily PhysicianPhoneAddress Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Reason For VisitHow 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?*YesNoPlease specify your treatment:Are you currently taking any medications or natural supplements?*YesNoPlease specify drug and/or supplements:Have you previously received chiropractic care/physiotherapy/massage therapy/acupuncture?*YesNoPlease specify:Medical History DetailsHave 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.)YesNoPlease specify:GENITOURINARY SYSTEM*(Kidney/bladder infections, Prostate, Painful/frequent urination, etc.)YesNoPlease specify:CARDIOVASCULAR SYSTEM*(High or low blood pressure, Stroke, Swollen ankles, Heart attack, etc.)YesNoPlease specify:IMMUNE & LYMPHATIC SYSTEM*(Lupus, Allergies, Chronic Fatigue Syndrome, etc.)YesNoPlease specify:MUSCULOSKELETAL SYSTEM*(Muscle/joint/bone disease such as Arthritis/gout, Extremity problems, Scoliosis, Postural problems, Fibromyalgia, etc.)YesNoPlease specify:DIGESTIVE SYSTEM*(Belching/gas, Constipation/diarrhea, Gall stone, Nausea/vomiting, etc.)YesNoPlease specify:RESPIRATORY SYSTEM*(Lung disease, Asthma, Sinusitis, etc.)YesNoPlease specify:NERVOUS SYSTEM*(Epilepsy, Numbness/tingling, Weakness, Tremors, Multiple Sclerosis, etc.)YesNoPlease specify:SENSORY SYSTEM*(Problems with balance, Dizziness, Ringing in ears, Changes ini vision, Smell, Hearing, Taste, etc.)YesNoPlease specify:OTHER*(Cancer, Migraines, Anemia, Unexplained pain or weight changes, Skin conditions, etc.)YesNoPlease specify:Previous x-rays/MRI/CT/Bone Scan?*YesNoPlease specify:Any falls, accidents, injuries?*YesNoPlease specify:Any surgery?*YesNoPlease specify:Is there a family history of any disease?*(Stroke, Cancer, High blood pressure, Heart disease, Diabetes, Arthritis, etc.)YesNoPlease specify:SignatureSignature*Date* Date Format: MM slash DD slash YYYY