Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
*
Home/Cell
(###)
###
####
Referred By
*
Google
Current Client
Family Chiropractic Centre
Instagram
TikTok
Other
Birthday
*
MM
DD
YYYY
Height
*
3 ft.
4 ft.
5 ft.
6 ft.
6 ft.
1 in.
2 in.
3 in.
4 in.
5 in.
6 in.
7 in.
8 in.
9 in.
10 in.
11 in.
Weight
Blood Type
Phone
*
(###)
###
####
Email
Occupation
*
Past Experience with Practitioners
*
(i.e. Chiropractor, Naturopath, Therapist, Homeopath, RMT, etc.)
List 1-5 health goals that you would like to attain for yourself, in order of priority:
*
How long have the above been a concern for you?
*
How long have you not felt well?
*
What do you believe, or suspect is the reason for your condition?
*
Surgeries (Include date performed)
*
If applicable
Past conditions or any other health concerns you think that I should be aware of (Include childhood illnesses)
*
List any vaccines that you have gotten (Including flu shots)
*
Include dates where possible
What physical trauma/accidents have you experienced?
*
Parents
Siblings
Grandparents
List any medications that you are taking now, or have in the past
*
Please include why you are/were taking them and for how long
List any supplements that you are currently taking
*
Check any of the following that you DO consume:
*
Of the items checked above. list how many of each you consume daily:
*
(ex. 3 coffees/day)
List any allergies that you know of:
*
What cravings do you have?
*
Do you exercise?
*
*If yes, list what kind and the frequency:
(ex. HIIT 3x/week)
Do you, or have you ever smoked?
*
*If yes, for how long?
What time do you go to bed?
*
What time do you wake up?
*
What position do you sleep in?
*
Fall asleep easily?
*
Restless sleeper?
*
Wake up during the night?
*
Feel rested upon waking?
*
Do you snore?
*
Do you have sleep apnea?
*
# Per day
*
Type
*
Please check all that apply
*
I have good concentration/focus
My weight is stable
I am constantly dieting
Start of last period
MM
DD
YYYY
Description:
Do you take birth control pills?
If yes, for how long?
Hormone replacement?
*
Check if applies to you:
Amalgam/Silver fillings?
*
If yes, how many and when?
Fillings removed?
*
If yes, how many and when?
Root Canals?
*
If yes, how many and when?
Teeth Removed?
*
If yes, how many and when?
Crowns or other metals?
*
Braces, retainer or partials
Any tattoos?
*
If yes, how many?
Previous occupation(s)?
*
Do you have a high-stress job or stressful relationship/situation?
*
Please provide a brief explanation
What emotional trauma/events have you experienced?
*
How do you manage/relieve stress?
*
What are your hobbies?
*
Current and previous
Do you use any of the following?
Check all that apply
For the checked boxes above, how often do you use each?
Ex. Hairspray 2x/day
Where have you lived?
*
How old is your home?
*
Remodelling/construction/new carpets/painting?
*
Are there hydro lines or transformers near your home/work?
*
What could get in the way or your plan of action?
*
How willing and able are you to invest in solving your problem?
*
What kind of investment budget do you have available if we are a good fit?
*
If we are a fit, how soon can you get started?
*
Do you have anyone else ( significant other, etc.) who should be on the call to help you make a decision?
