Download Personal History Today`s Date: Name: Sex: M 口 F 口 Pregnant

Personal History
Today’s Date: _________________
Name: ___________________________________________ Sex: M
 F
Pregnant Y
 N
Birthdate: (mm/dd/yy) ____ / ____ / ____
Address: _________________________________________
City: ________________________ Prov: ____ Postal Code: ___________
Home Phone: _______________________
Work Phone: ______________ Cell Phone: ______________
E-mail Address _____________________________________ your e-mail will only be used to inform you of office hour
changes, to confirm appointments or in the event we cannot contact you by phone.
SK Health Services # :____________________________________
Name of Family Physician: __________________________________
Referred By: _____________________________________________
Type of work: ____________________________________________
Next of kin: Name:_________________________________ Phone:___________________________
Current Health
Main/Current Health Concern(s): ______________________________________________________________
Secondary Concerns: _______________________________________________________________________
Any other doctors seen for this concern? Y
 N
Types? ________________________________________
Type of Treatment: _____________________________ Results: ___________________________________
Place an X on the scale to indicate the severity of your discomfort (if applicable):
Least 1
2
3
4
5
6
7
8
9
10
Worst
Does this problem interfere with:
Work: Yes
 No 
Medications you take now:
Family/Social Time: Yes

No

Your Hobbies/Sports: Yes


 Nerve Pills  Painkillers/Muscle Relaxants  Blood Pressure Medicine
 Insulin
 Other: _________________________________________
Past Health History
Major Surgery / Operations: ________________________________________________________
 Childhood Traumas ____________  Motor Vehicle Accidents: ________________
 Sports Injuries: ________________________  Work Injuries: _________________________
 Hospitalization (other than above): _________________________________________________
Previous:
No
Below is a list of symptoms or diseases that may seem unrelated to the purpose of your appointment.
However, these questions must be answered carefully as these problems can affect your overall course of
chiropractic care.
Check any of the following you have had in the past six months, even if they do not seem related to your
current problem:
Nervous System
 Nervous
 Numbness
 Dizziness
 Forgetfulness
 Confusion / Depression
 Fainting
 Convulsions
 Cold / Tingling Extremities
Musculo-Skeletal
 Low Back Pain
 Pain Between Shoulders
 Neck Pain
 Arm Pain
 Joint Pain / Stiffness
 Walking Problems
 Difficulty Chewing /
Clicking Jaw
 General Stiffness
Sleeping Position
 Back
 Side
 Stomach
General
 Fatigue
 Allergies
 Loss of Sleep
 Fever
 Headaches
C-V-R
 Chest Pain
 Short Breath
 Blood Pressure Problems
 Irregular Heartbeat
 Heart Problems
 Lung Problems /
Congestion
 Varicose Veins
 Ankle Swelling
 Stroke
EENT
 Vision Problems
 Dental Problems
 Sore Throat
 Ear Aches
 Hearing Difficulty
 Stuffed Nose
Lifestyle Stress Levels
 High
 Moderate
 Very Little
 None
Check any of the following
diseases you have had:
 Arthritis
 Diabetes
 Epilepsy
 Cancer
 Heart Disease
 Thyroid
 Eczema
 Psoriasis
Gastro-Intestinal
 Black / Bloody Stool
 Poor / Excessive Appetite
 Excessive Thirst
 Frequent Nausea
 Vomiting
 Diarrhea
 Constipation
 Hemorrhoids
 Liver Problems
 Gall Bladder Problems
 Weight Trouble
 Abdominal Cramps
 Gas / Bloating After Meals
 Colitis
Male/Female
 Menstrual Irregularity
 Menstrual Cramping
 Vaginal Pain Infections
 Breast Pain / Lumps
 Prostate / Sexual
Dysfunction
Female
When was your last period?
______________________
Are you pregnant?
Yes  No  Not Sure 
Genito-Urinary
 Bladder Trouble
 Painful / Excessive
Urination
 Discoloured Urine
Reviewed: ________________
Date:_____________________
Please outline on the
diagram the area of your
discomfort and any radiation
of pain
There are risks and possible risks associated with manual therapy techniques used by
doctors of chiropractic. In particular you should note:
a) While rare, some patients may experience short term aggravation of symptoms are muscle and
ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib
fractures have also been known to occur following certain manual therapy procedures;
b) There are reported cases of stroke associated with visits to medical doctors and chiropractors.
Research and scientific evidence does not establish a cause and effect relationship between
chiropractic treatment and the occurrence of stroke rather, recent studies indicate that patients
may be consulting medical doctors and chiropractors when they are in the early stages of a
stroke. In essence, there is a stroke already in progress. However, you are being informed of this
reported association because a stroke may cause serious neurological impairment or even
death. The possibility of such injuries occurring in association with upper cervical adjustment is
extremely remote;
c) There are rare reported cases or disc injuries identified following cervical and lumbar spinal
adjustment, although no scientific evidence has demonstrated such injuries are caused, or may
be caused, by spinal adjustments or other chiropractic treatment;
d) There are infrequent reported cases of burns or skin irritation in association with the use of
some types of electrical therapy offered by some doctors of chiropractic.
I acknowledge I have read this consent and I have discussed, or have been offered the
opportunity to discuss, with my chiropractor the nature and purpose of chiropractic
treatment in general, (including spinal adjustment), the treatment options and
recommendations for my condition, and the contents of the Consent.
I consent to the chiropractic treatment recommended to me by my chiropractor including
any recommended spinal adjustments.
I intend this consent to apply to all my present and future chiropractic care.
Dated this ___________ day of ___________________, 20______.
Patient Signature (Legal Guardian)
Witness of Signature
________________________________
________________________________
Name: __________________________
(please print)
Name: __________________________
(please print)