PERSONAL INFORMATION
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Marital Status
Please Select
Single
Married
Common Law
Divorced
Widowed
Gender
Female
Male
Non-binary
Other
Number of Children
Family Doctor
Occupation
CONTACT INFORMATION
Address
*
City
*
Postal Code
*
Work Phone #
Cell/home Phone #
E-Mail
*
HOW DID YOU HEAR ABOUT OUR OFFICE?
Please Check One:
Internet Search
Family Member
Friend
Co-Worker
Health Care Professional (eg. Physician, Physiotherapist, Massage Therapist etc.)
Other
Please let us know who we can thank for referring you to our office:
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OUR HEALTH GOALS:
Where is/are the problem(s) (if visits is not just for overall health)? Please use the lines below to explain.
How long has this been going on?
When did this incident occur?
Is this related to:
Workplace Injury
Sports
Personal Injury
Auto Accident
Other
Do you have:
Pain
Numbness
Tingling
Aches
Is your pain:
Sharp
Dull
Throbbing
Constant
Intermittent
Are your symptoms affected by:
Sitting
Standing
Walking
Bending
Lying Down
Weather
Other
Do your symptoms interfere with:
Work
Sleep
Daily Activities
Hobbies and Leisure Activities
On a scale of 1-10 (1 = least, 10 = most), please rate the severity of your symptoms
1
2
3
4
5
6
7
8
9
10
Least
Worst
1 is Least, 10 is Worst
Do you get headaches?
Yes
No
How often?
Are you receiving care from any other health professionals?
Yes
No
If Yes, please name them and their speciality:
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GENERAL HEALTH HISTORY
Past injuries can affect present health.
Please check all that apply:
Falls/Accidents
Sports Injuries
Head Injuries/Concussions
Broken Bones
Knocked Unconscious
Car Accidents
Surgery
Joint Replacement
Stroke
Pacemaker
If you answered Yes to any of the above, please describe:
Please list any medications you are taking and the reason for the medication
Please list any vitamins or supplements that you are taking
Do you have any other health concerns we should know about?
Yes
No
If Yes, please describe:
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If you had a magic wand, what 3 health conditions or issues would you like to improve?
*
Is there anything else that you would like us to know about you?
Yes
No
If Yes, please tell us:
Thank you so much for filling out the Low-Level Laser & PEMF New Patient Health Questionnaire. We look forward to helping you with your specific health concerns and overall well-being!
The Team at Santé Chiropractic and Wellness Centre
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