* We communicate appointment reminders, invoices, receipts, exercise programs & health tips via email. We hate spam, but wereally value educational information. Do we have permission to utilize your email address ? Yes No

Family Medical Doctor’s Name:

Date of last MD visit:

Date of last physical examination:

What therapies have you previously received? Chiropractic Massage Acupuncture Physiotherapy

Clinic:

Reason:

Sex: Male Female Birthdate: Age: Marital Status:

Alberta Health Care #: Street Address:

Cell#: Postal Code: City: Prov:

Home #: Email:

Occupation: Employer:

Emergency Contact: Relationship: Phone #:

DD/MM/YYYY

DD/MM/YYYYDate: Full Name: Preferred Name:

* Communication between healthcare providers can greatly improve the quality and safety of patient care. If necessary, do youconsent to allow your health provider at PHP to contact your medical doctor? Yes No

Do you have a private insurance plan? No Yes (Self) Yes (Spouse) Yes (Parent)

Name of primary policy holder (Spouse/Parent):

Policy #:

Member ID: Group #: (ABC Only)

Is this a Workman’s Compensation Case (WCB)? No Yes

Date of Accident:

Is this a Motor Vehicle Accident Case (MVA)? No Yes

Date of Accident:

Referred by Friend/Family Referred by Medical Doctor Internet/Website Street Sign

Referred by Trainer Walk In Health Care Event

*Whom may we thank for this referral?

Alberta Blue Cross (ABC)

Green Shield

Chamber of Commerce

Industrial Alliance

Other:

SunLife

Standard Life

Desjardins

Johnson

Great West Life

SSQ Financial

Cowan

Manulife

Which Company?

Other:

HOW DID YOU FIND US?

Chiropractic Intake Form

Patient Information 1/10

Medical Information 2/10

Page /31 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //

Extended Health Benefits & Other Insurance 3/10

How Did You Hear About Us? 4/10

Primary Complaint:

Have you had this before? No Yes; When:

What is the character of the pain?

Is the Condition: Work-Related Auto-Related Fall Sports-Related Other:

Please rate your pain: (LEAST) 0 1 2 3 4 5 6 7 8 9 10 (WORST)

When do you feel the pain? Constantly Intermittently Only at Night Only in the Morning

Does the pain radiate down your legs or arms? No Yes; Describe:

Have you seen anyone else for this condition? No Yes; Who:

Have you had any imaging for this condition: X-Ray CT MRI Ultrasound Date:

What aggravates your pain? Sitting Standing Rest Bending Lifting Exercise Weather Changes

What relieves your pain? Rest Movement Heat Ice Massage Medication:

Does this problem interfere with: Work Family & Social Life Sports & Hobbies Sleep

What is your commitment to correcting this problem: 0 1 2 3 4 5 6 7 8 9 10

Do you have any secondary complaints?

''''''''''''''

E/$I!G/$%)1![!E/+6#+5$:3/4!W:V'+0![!>*#+)(!P/1$2!F%-:-3!!!!!!\]]^!B%2#&!;+-,/!>H4!F$%7$+04!9J4!"_>!_S\!!! !!̂ ]` C_ab Cb`_\ !

@9++%&#'3%"0#4'@*&.$#$*&'7A*+'(&B9+C'

E+-5$+0!F#5*%$-:)<!=================================================!!H1/:!.-.!)1-(!2/7-:R!==============================!

G$,/!0#'!1$.!)1-(!2/6#+/R!! !D#!! !N/(c!&1/:<!===================!!W(!-)!7/))-:7<!!!H#+(/!! !J/))/+!! !D#)!F1$:7-:7 !

W(!)1/!3#:.-)-#:<!!!H#+I CP/%$)/.!!! !9')# CP/%$)/.!!! !>*#+)(CP/%$)/.!!! !A$%%!!!O)1/+<!==============================!

H1$)!-(!)1/!31$+$3)/+!#6!)1/!*$-:R!!;'%%![!9310!!!!>)-66![!"-71)!!! !>1$+*!!! !E-:(![!D//.%/(!!! !D'52!! !J'+:-:7!! !

E%/$(/!+$)/!0#'+!*$-:<!!!KSB9>" L!!!!]!!!!!!d!!!!!!!_!!!!!!!`!!!!!!!^!!!!!!!\!!!!!!!e!!!!!!!b!!!!!!!a!!!!!!!f!!!!!!!d]!!!!!!KHOP>" L!

H1/:!.#!0#'!6//%!)1/!*$-:R!!! !F#:()$:)%0!!!! !W:)/+5-))/:)%0!!!! !O:%0!$)!D-71)!!!!!O:%0!-:!)1/!@#+:-:7!

;#/(!)1/!*$-:!+$.-$)/!.#&:!0#'+!%/7(!#+!$+5(R!! !D#!!! !N/(c!;/(3+-2/<!================================================!

H1$)!$77+$,$)/(!0#'+!*$-:R!! !>-))-:7!! !>)$:.-:7!!! !J/:.-:7!!! !S-6)-:7!!! !B?/+3-(/!!! !H/$)1/+!F1$:7/(!!! !P/()!

H1$)!+/%-/,/(!0#'+!*$-:R!! !P/()!!! !@#,/5/:)!!! !G/$)!!! !W3/!!!!@$(($7/!!! !@/.-3$)-#:<!==========================!

G$,/!0#'!(//:!$:0#:/!/%(/!6#+!)1-(!3#:.-)-#:R! !D#!!! !N/(c!&1#<!======================================================!

G$,/!0#'!1$.!$:0!-5$7-:7!6#+!)1-(!3#:.-)-#:<!! !gCP$0!!!! !F"!!!! !@PW!!!!!h%)+$(#':.!!!!!;$)/<!=======================!

;#/(!)1-(!*+#2%/5!-:)/+6/+/!&-)1<!!!H#+I!!!!! !A$5-%0![!>#3-$%!S-6/!!!!!>*#+)(![!G#22-/(!!! !>%//*!

H1$)!-(!0#'+!3#55-)5/:)!)# !3#++/3)-:7!)1-(!*+#2%/5<!!!]!!!!!d!!!!!!_!!!!!!`!!!!!!^!!!!!!\!!!!!!e!!!!!!b!!!!!!a!!!!!!f!!!!!!d]!!!!!

;#!0#'!1$,/!$:0!(/3#:.$+0!3#5*%$-:)(R!==================================================================================!

================================================================================================================================

=!DC,E#*,';$"F+", '

E%/$(/!'(/!)1/!(052#%(!2/%#&!)#!5$+I!$%%!#6!)1/!$+/$(!#:!)1/!.-$7+$5!)1$)!JB>"!+/*+/(/:)!)1/!*$-:!$:.!

(/:($)-#:(!)1$)!0#'!$+/!FhPPBD"SN!/?*/+-/:3-:7<! !

!

When did this begin?

Is it getting: Worse Better Not Changing

Dull & Achy Numb Stiff & Tight Pins & Needles Sharp Burning

Please use the symbols below to mark all of the areas on the diagram that BEST represent the pain and sensations that you are

CURRENTLY experiencing:

Page /32 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //

Current Health Condition &/Or Injury 5/10

Symptom Diagram 6/10

O)1/+<!==============================

N/(c!;/(3+-2/<!================================================

@/.-3$)-#:<!==========================

==============================================

h%)+$(#':.!!!!!;$)/<!=======================

;#!0#'!1$,/!$:0!(/3#:.$+0!3#5*%$-:)(R!==================================================================================!

=================================================================================================

Have You Ever Had...

Fracture: No Yes; where/ when:

Major Surgery: No Yes; where/when:

Car Accident: No Yes; when:

A Concussion: No Yes; when/ how:

Been Hospitalized: No Yes; when/why:

Been Diagnosed With: Cancer HIV/AIDS Hepatitis A/B/C Other: When:

Do you have any allergies: No Yes; List:

Please list any medications/supplements that you are currently taking:

High Blood Pressure: No Yes; when:

High Cholesterol: No Yes; when:

Are you pregnant? No Yes; Due Date:

# of Past Pregnancies: # of Children:

Is there a family history of:

*Mother’s Side:

*Father’s Side:

Heart Disease Stroke Cancer Diabetes Arthritis Other

Are you currently a smoker? No Yes; amount:

Do you exercise regularly? No Yes; type & frequency:

Do you consume alcohol? No Yes; amount/frequency:

Did you smoke previously? No Yes; when:

Coffee? No Yes; amount:

Do you have a healthy & balanced diet? No Don’t Know Yes, I think so Yes, definitely

What are your stress levels? Extreme High Moderate Low Very Minimal

Page /33 5004 Elbow Drive SW Calgary, AB, T2S 2L5 403-287-7325// //

Health History 7/10

Family History 8/10

Lifestyle 9/10

Health Status Survey 10/10

Please check the box of any conditions or symptoms that you have had in the past six months:

Fever

Fainting

Night Pain

Headaches

Loss of Sleep

Loss of Weight

Anxiety/Nervous

Excessive Sweating

General:

Angina

Chest Pain

Varicose Veins

Ankle Swelling

Poor Circulation

Previous Stroke

Irregular Heartbeat

Previous Heart Attack

Cardiovascular:

Dizziness

Paralysis

Nausea

Convulsions

Clumsiness

Blurred Vision

Loss of Balance

Numbness/Tingling

Neurological:

Asthma

Sore Throat

Frequent Colds

Chronic Cough

Sinus Infections

Spitting up Blood

Spitting up Phlegm

Difficulty Breathing

Respiratory:

Kidney Infection

Menopause

Painful Breasts

Prostate Trouble

Trouble Urinating

Blood in Urine/Stool

Painful Menstruation

Irregular/Absent Cycle

Genitourinary:

Earaches/Infection

Hearing Difficulty

Eye Pain

Ringing in Ears

Worsening Vision

Eyes/Ears/Nose/Throat:

Shoulder/Arm Pain

Knee/Leg Pain

Hip/Groin Pain

Wrist/Hand Pain

TMJ/Jaw Pain

Fibromyalgia

Arthritis

Disc Herniation

Low Back Pain

Mid Back Pain

Neck Pain

Elbow Pain

Muscle & Joint:

Sciatica

Ankle/Foot Pain

Gout