New Patient Information Form - Family Chiropractic Centre

Section One Tell Us About Yourself
Welcome To Our Clinic
Name _____________________________ Date of Birth d_____m ______ y ________
Address _____________________________ Height _________ ft. _________in.
City _____________________________ Sex male female Weight_______lbs.
Postal Code _____________________________ single married widow(er)
Home Phone _____________________________ divorced separated common law
Work Phone _____________________________ Children _______ girls _______boys
Occupation _____________________________ Family Doctor _______________________
Employer _____________________________ City ________________________
Section Two Tell Us About Your Health
1) What is your chief health concern?
______________________________________________________________________________
2) When did you first notice the symptoms?
______________________________________________________________________________
3) Are there any other health concerns you have?
______________________________________________________________________________
4) Any falls, fractures or breaks?
FAMILY CHIROPRACTIC CENTRE
Michael Pernfuss D.C Scott Huehn B.Sc., D.C., FATA Greg Goodbrand B.Sc.,D.C
Shikha Sareen B.Sc., D.C Kerri-Lynn Vallentin B.Sc.,D.Ch. Mark Phillips R.M.T.
______________________________________________________________________________
5) Please check if you have experienced any of the following (past or present)
headaches fainting breathing difficulties numbness in leg
neck pain/stiffness dizziness stomach problems urination problems
ear aches midback pain low back pain bowel troubles
numbness in arms rib pain hip pain painful
fever shoulder pain leg & foot trouble menstruation

6) Describe the average daily activities/motions of your body (eg. 1hr driving, 8hrs sitting, 3 hrs misc.)
________________________________________________________________________________
____________________________________________________________________________
7) Have you ever been involved in any motor vehicle accidents?
No Yes If yes, please describe, including approximate dates, and any injuries you sustained.
______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do You Have A Current Claim No Yes - Ins. Company _______________ Policy #______________
8) Have you ever been injured at your place of employment?
No Yes If yes, please describe, including approximate dates and any injuries you sustained.
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
Do You Have A Current Claim No Yes - SIN #_________________ Claim # ________________
9) Have you ever consulted a Chiropractor before today? No Yes If yes please describe
When ________________ Dr.’s Name ______________________ City ____________________
When ________________ Dr.’s Name ______________________ City ____________________
10) How did you find out about our clinic?
______________________________________________________________________________
Section Three Tell Us About Your Health Insurance
1) Are you entitled to benefits through any of the following
Yes; Special Income/Ontario Works
Yes; Indian Affairs # _______________________________
Yes; Veteran Affairs # ______________________________
2) Do you have private health insurance through a medical/dental plan? No
(eg. Sun Life, Great West Life, Manulife etc.)
Yes; my own plan Yes; my spouse’s plan Yes; my parent’s plan
Company________________ Company________________ Company________________
Plan/Policy#______________ Plan/Policy#______________ Plan/Policy#______________
ID/Cer/Emp#______________ ID/Cer/Emp#______________ ID/Cer/Emp#______________
Name ___________________ Name ___________________
Signature_______________________________________ Date_____________________
136 Young Street, Hamilton, ON L8N 1V6 • 905-528-6426 • fax 905-528-0090