elkinnaturalhealth.com - Elkin Natural Health Centre

Elkin Natural Health Centre
Name:

First NameLast Name
Marital Status:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you wish to be contacted?

Home ⁭Office⁭ Cell ⁭Email
Phone Number Home:
Please enter a valid phone number.
Phone Number Work:
Please enter a valid phone number.
Phone Number Office:
Please enter a valid phone number.
E-Mail:
example@example.com
Occupation:
S.I.N#:
Date of Birth:

MonthDayYear
Date
Is this a Worker’s Compensation Claim?
Medical Doctor:
CONGRATULATIONS ON YOUR DECISION TO BEGIN CHIROPRACTIC CARE. IN ORDER FOR US TO SERVE YOU BEST, PLEASE COMPLETE THE FOLLOWING:
Last Chiropractor:
Date of Last Visit:

MonthDayYear
Date
What is the purpose of your decision to begin Chiropractor Care?

Pain Relief ⁭Stress Reduction ⁭Improved General Health and Well Being ⁭Improved PostureSpinal CorrectionImproved Physical and Mental Performance ⁭To improve a specific aspect of my health
Details:
Are other members of your family receiving Chiropractic care?

YesNoN/A
Are you taking any medication?

YesNo
If yes, what:
Were you ever a smoker?

YesNo
From:

MonthDayYear
Date
To:

MonthDayYear
Date
Referred to our office by:
Check any of the following that you have experienced in the past, or are experiencing currently:

Mood Swings / depressionPain between shoulder blades⁭Anger / Loss of temperChest pain / Heart palpitations⁭Chronic colds ⁭History of cancer or heart disease⁭Allergies ⁭Low back pain⁭Sinus Problems ⁭Leg pain / Sciatica⁭ Tension and / or migraine headaches ⁭Digestive problems⁭ Neck pain ⁭Females: Irregular Menstrual cycles⁭ Asthma ⁭Other female disorders⁭ Numbing / tingling in arms or hands ⁭Difficulty sleeping⁭ Carpal Tunnel Syndrome⁭Fatigued / tired⁭Shoulder pain ⁭Skin Problems
Which of the above is the worst?
How long have you had it?
Which of the following is most affected when your health is at its worst?

Work⁭ Sleep⁭ Home life⁭ Time with spouse or children⁭ Relationships (family, children, friends, co-workers) ⁭Exercise / sports⁭ Spiritual relationships ⁭Attitude⁭ Hobbies ⁭Energy levels
Should be Empty: