Bow River Chiropractic Clinic

Name: _____________________ ____________________________ Birth Date: _________________ Age: _____

First Last	Month / Day / Yr

Height: _______ Weight: _______ Sex: M  F  Marital Status: ______________ Children: Boys ___Girls ___

Address: ___________________________________ City/Town:___________________ Postal Code ____________

Phone :(H) _______________ Other: Work  Cell  ___________________ Occupation/Employer _______________

For appointment reminders &/or receipts:	Email (optional): _______________________________________________

Alberta Health Care #: ___________________________	Additional Insurance Coverage: Y / N

Emergency contact: Name: __________________________________ Number: _______________________________

Family Physician: ________________________ Do you consent to informing your physician of your progress Y / N

How did you hear about the clinic:  Website  Phonebook  Newspaper Referral (Name)____________________

Current Health Condition

Reason for Appointment: ___________________________________________________________________________

When did this condition begin ? ______________________________________________________________________

Have you ever had similar problems ? Yes  No 

What do you believe caused this condition ? _____________________________________________________________

Have you had X-Ray, MRI or other tests for this condition ? What tests & when ? ______________________________

Is this condition related to work ? Yes  No  Has your employer been notified ? Yes  No 

Motor vehicle accident ? Yes  No  Date of Injury (D/M/Y): _______________

Please describe what activities you do on a daily basis (for example, lifting, prolonged sitting or standing)

_____________________________________________________________________________________

Can you perform your daily home activities ? Yes  Yes, only with help  Not at all 

Can you perform your daily work activities ? All activities  Only some  Not at all 

List any medications, drugs, vitamins or supplements you are currently taking: __________________________

_________________________________________________________________________________________

Have you had previous Chiropractic care ? Yes  No  Doctor: ____________________ Date: __________

List any major surgeries, hospitalizations, illnesses or injuries: _______________________________________

__________________________________________________________________________________________

Please continue on reverse side →→→→

HEALTH HISTORY QUESTIONNAIRE

Name: ______________________________________________

Have you ever been diagnosed or told you have any of the following ?

Please circle the correct response.

- High blood pressure.................................................................................Yes No

- Diabetes.................................................................................................. Yes No

- Heart or blood diseases.......................................................................... Yes No

- Cancer, Where? ..................................................................................... Yes No

- Bone spurs on the neck bones (cervical sprain)..................................... Yes No

- Whiplash injury (flexion-extension injury, cervical sprain)....................... Yes No

- Have you or any of your relatives ever suffered a stroke? ..................... Yes No

- Were you ever a smoker? From _________ To __________............. Yes No

- Do you take any medication on a regular basis?.................................... Yes No

- Visual disturbances (blurring, loss, double) .......................................... Yes No

- Hearing disturbances (loss, ringing, other noise).................................. Yes No

- Slurred speech or other speech problems............................................. Yes No

- Difficulty swallowing............................................................................... Yes No

- Dizziness................................................................................................ Yes No

- Loss of consciousness, even momentary blackouts.............................. Yes No

- Numbness, loss of sensation, strength or weakness in the face,

fingers, hands, arms, legs or any other parts of the body……………….. Yes No

- Sudden collapse without loss of consciousness..................................... Yes No

- Are your feet sore on a regular basis ……………………………………….Yes No

- Do you spend a good portion of the day walking or standing …………… Yes No

- Does walking or running cause joint pain (foot, ankle, knee, hip) ………..Yes No

- Do you have visible foot problems (bunions, flat feet) ? …………………..Yes No

Indicate the location of your pain by shading in the appropriate area

Indicate the severity of the pain by circling a number.

| 0 1 2 3 4 5 6 7 8 9 10 |

No Pain	Extreme Pain