Vidachiropractic- new paient

Past History

Have you suffered with any of this or a similar problem in the past? *

Yes No

Have you tried any other forms of treatment? *

Yes No

Please identify any and all types of jobs you have tried in the past that have imposed any physical stress on you or your body

If you have ever been diagnosed with any of the following conditions, please indicate if it was in the Past, Currently, or Never have had:

Never

Currently

Past

Broken Bone

Dislocations

Tumors

Rheumatoid Arthritis

Fracture

Cancer

Disability

Heart Attack

Osteo Arthritis

Diabetes

Other serious conditions

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem (including auto or related accidents):

How long ago

Type of Care Received

By Whom

Injuries

Surguries

Childhood Diseases

Adult Diseases

Do you also suffer from any of the following?

Social History

Smoking *

Cigars Pipe Cigarettes None

How Often?

Daily Weekends Occasionally Never

Alcoholic Beverage: Consumption Occurs *

Daily Weekends Occasionally Never

Recreational Drug Use: How often? *

Daily Weekends Occasionally Never

Prescription Drug Use: How often? *

Daily Weekends Occasionally Never

Please list all medications and condition prescribed for:

OPT-IN CONSENT FOR E-MAIL

I would like to communicate by email with Vida Chiropractic.
I will be responsible for maintaining any information regarding my care that I have saved onto my personal computer
I understand that my email authorization and a copy of the email guidelines I have received will become part of my permanent medical record.
I agree to follow the guideline for email communication with Vida Chiropractic and will use email for non-emergency purposes only.
Emails containing transitory information (routine or short term transactions, and contain little or no information of ongoing value, i.e. confirmation of appointments) will be securely deleted by the Clinic.
Email correspondence containing clinical or significant information will be entered into my permanent medical record by Vida Chiropractic.
I agree to inform Vida Chiropractic if my email address changes.
I understand that the Clinic will normally respond to email communications within 1 business day. If I have not heard from the Clinic by this time, I will phone the Clinic.

I agree to receive email reminders from Vida Chiropractic for my appointments. To opt-out of this reminder service, simply notify us by phone 250-861-5444 or email at office@vidachiropractic.ca. I agree to receive emails from Vida Chiropractic regarding office closures, special events and updates or promotions. To opt-out of this service, simply notify us by phone 250-861-5444 or email us at office@vidachiropractic.ca. I agree to receive Vida Chiropractic’s monthly newsletter containing chiropractic research, chiropractic testimonials and information pertaining to health and well being. To opt-out of this service, simply notify us by phone 250-861-5444 or email us at office@vidachiropractic.ca.

The email I would like to have on file is a personal, non-shared, confidential email. I assure Vida Chiropractic that information sent to this email is secure and does not place Vida Chiropractic at risk of breaching confidentiality or privacy regulations.

The Statements made on this form are true to the best of my knowledge and I consent to allow Vida Chiropractic to further evaluate my condition with an exam and other tests as deemed necessary by the doctors.

Name:

Parent or guardian if under 18

Signature

Please use your mouse or your trackpad to sign in the box above. Clear

Patient Demographics