Vidachiropractic- new paient

Name *

First Name Last Name

Birth Date *

Age *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email Address *

example@example.com

Cell Phone # *

Alternative Phone #

Whom may we thank for referring you to this office? *

BC Care Card Number or Personal Health Number: *

Employer

Occupation

Marital Status

Single Married Common-law Widow

Number & Age of Children (Under 21)

Name of Emergency Contact

Emergency Contact Phone #

Relationship to Emergency Contact

History of Complaint

Please identify the complaints that have brought you to our office (Please describe in detail):

Primarily *

Secondary

Third

Fourth

On the scale of 0 to 10, with 10 being the worst pain, rate your above complaints:

Primary or chief complaint:

When did the problem(s) begin? *

When is the problem at its worst?

AM PM mid-day late PM

How long does it last?

It is constant I experience it off and on during the day It comes and goes through the week.

How did the injury happen? *

Have the condition(s) ever been treated by anyone in the past?

Yes No

How would you describe your symptoms? *

Radiating Burning Dull Aching Numbness Sharp/Stabbing Tingling

Where on your body is it Radiating

Where on your body is it Burning

Where on your body is it Dull

Where on your body is it Aching

Where on your body do you feel Numbness

Where on your body does it feel Sharp/Stabbing

Where on your body does it feel Tingling

What relieves your symptoms? *

What makes them feel worse? *

List Restricted Activities *

Is your problem the result of any type of accident? *

Yes No

Is it related to a Worker’s Compensation injury? *

Yes No

Identify any other injury(s) to your spine, minor or major, that the doctor should know about:

Have you had x-rays of your spine in the last 2 years? *

Yes No

Patient Demographics