Confidential Patient Information and Medical History Contact InformationName* First Last Date* 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* Male Female Prefer not to say Home Phone*Business PhoneCellEmail* Occupation Employer Physician Contact InformationFamily Physician PhoneAddress 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?* 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 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.) 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: SignatureSignature*Date* MM slash DD slash YYYY
