CONFIDENTIAL PATIENT HEALTH RECORD Step 1 of 3 33% Today Date:*What is today's date?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name*Please provide your full name. Prefix First Last Suffix Address*What is your current address? Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone Number:*Work Phone Number:Cell Phone Number:Email Referred by:How did you hear about us?Date of Birth:*Please select your date of birth.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*How old are you?Sex*MFMWSDNumber of Children:Occupation:*Where do you currently work?Are you pregnant, or is there a possibility of pregnancy?*YesNo CURRENT HEALTH CONDITIONHave you had previous Chiropractic Care:*YesNoDate of Last Appointment:When was the last appointment you had with a chiropracter?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Previous Dr's Name:What is your chief concerns?How long have you had this condition?Have you had simmiliar conditions in the past?What activities aggravate your condition?Is your condition getting progresively worse?YesNoConstantComes and GoesIs the condition interferring with your...?WorkSleepDaily RoutineOtherOthers who have treated this condition:Other Concerns?*Do you have any other concerns we should be made aware of?How long has it been since you really felt good?Drugs you now take:*Please select more than one if applicable? Blood Pressure Pills Insulin Muscle Relaxants Pain Killers Tranquilizers Birth Control Pills Vitamins/Minerals Recreational Drugs Others None PAST HEALTH HISTORYFamily and social health history:Have you been in an auto accident?*Past YearPast 5 YearsOver 5 YearsNeverDescribe:If you have been in accident please describe in detail about this accident and how it effected you?Hospitalizations:Accidents/Falls/Other Physical or Emotional Trauma?Family and social health history?Date of last physical examination?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Who is your Family Physician:Would you like your physician to be informaed about the services provided for you?YesNoYour Family Physicians Address: Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code CommentsThis field is for validation purposes and should be left unchanged.
