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Download File - Diamond Valley Chiropractic
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Diamond Valley Chiropractic Clinic Carrington – Morris Professional Corporation Sheep River Centre, 205 Centre Avenue W., Black Diamond, AB. T0L 0H0 THE INFORMATION YOU PROVIDE IS FOR THE CONFIDENTIAL USE OF THIS OFFICE AND WILL ONLY BE RELEASED WITH YOUR WRITTEN CONSENT OR IF YOUR TREATMENT IS COVERED UNDER THE WORKER`S COMPENSATION ACT. Health Insurance Company____________________Policy#_______________Member ID #________________ Rollover date___________________Alberta Blue Cross ID # _______________________ Group #_________ Date AHC # ______________________________ Mr Mrs Ms (X-ray Purposes) Name Complete Address Postal Code Phone: H Age E-mail Would you like an appt. reminder: Y N Birth Date (m/d/y) Marital Status B C If Yes, by: e-mail____text_____ cell phone provider _____________ Name of Spouse Single Number of Children Married Widowed Divorced Separated Occupation Is this a Worker’s Compensation Case? NO If yes: Date of Injury SIN Is this a Personal Injury Case? NO YES Have You Had Previous Chiropractic Care? NO YES YES If yes: Describe Name of Doctor Address What were you treated for? Were X-Rays Taken? NO What is your major complaint? Do you have any other complaints? Please list surgical operations and approximate dates they were performed Are you currently on any medication? Name of Medical doctor? Have you ever been in an automobile accident? If yes: Describe Address NO YES YES Do you or a family member have a history of any of the following? HIV Bed Wetting Multiple Sclerosis Alcoholism Depression Stomach Ulcers Allergies Diabetes Drug Addiction Arthritis Stroke Other Asthma Heart Disease Cancer Epilepsy Please indicate if you have ever suffered from any of the following conditions Appendicitis Tuberculosis Arthritis Heart Disease Mumps Pleurisy Malaria Diabetes Whooping Cough Pneumonia Influenza Eczema Chicken Pox Venereal Disease Typhoid Fever Measles Polio Psoriasis Alcoholism Diphtheria Anaemia Goitre Rheumatic Fever Stroke Scarlet Fever Cancer Epilepsy Mental Disorder Small Pox Transient Ischemic Attack Please indicate if you have experienced any of the following symptoms within the last year Low Back Pain Pain Between Shoulders Neck Pain Arm Pain Walking Problems Painful/Clicking Jaw Numbness Paralysis Dizziness Forgetfulness Fainting Convulsions Cold/Tingling Hands/Feet Allergies Loss of Sleep Fever Night Pain Night Sweats Headaches Poor/Excessive Appetite Excessive Thirst Nausea Vomiting Diarrhea Constipation Haemorrhoids Liver Trouble Gas/Bloating After Meals Joint Pain/Stiffness Heart Burn Black/Bloody Stool Colitis Bladder Trouble Painful/Excessive Urination Discoloured/Bloody Urine Chest Pain Shortness of Breath Blood Pressure Problems Heart Problems Lung Problems/Congestion Varicose Veins Ankle Swelling Vision Problems Dental Problems Sore Throat Ear Aches Hearing Difficulties Stuffed Nose MEN ONLY Prostate/Sexual Dysfunction Genital Sores /Herpes WOMEN ONLY Menstrual Irregularity Menstrual Cramping Vaginal Pain/Infections Breast Pain/Lumps Are you pregnant? When was your last period? yes no
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