The purpose of our office is to restore and maintain the health of our patients through natural chiropractic methods. Please complete this confidential health questionnaire fully and accurately. The more we know about the overall picture of your child's health, the better we will be able to help you.Patient DemographicsName*Birth Date* MM slash DD slash YYYY Age*Gender (Male / Female)*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Whom may we thank for referring you to this office?BC Care Card Number or Personal Health Number:EmployerOccupationMarital Status (Single, Married, Common-Law, Widow)Spouse / Partners NameSpouse / Partners EmployerNumber & Age of Childer (Under 21)Name of emergency contactPhone NumberRelationshipHistory of ComplaintPlease identify the complaints/reasons for your child's visit to our office (i.e. wellness check-up, injury):Complain / Reason #1Complain / Reason #2Complain / Reason #3On the scale of 0 to 10, with 10 being the most significant, rate the above complaints by entering the number:Complain / Reason #1 (Scale 0-10)Complain / Reason #2 (Scale 0-10)Complain / Reason #3 (Scale 0-10)When did the problem(s) begin?When is the problem at its worst? (select one) AM PM Mid-Day Late PM How long does it last (select one) It is constant I experience it off and on during the day It comes and goes through the week Have the condition(s) ever been treated by anyone in the past: Yes or No?If yes, when?By Whom?How long were you under their care?What were the results?Name of Previous ChiropractorPlease list the areas of your body where the symptoms are occuring with the following letters: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/Stabbing T = TinglingWhat relieves your symptoms?What makes them feel worse?Is this problem the result of an accident or injury: Yes or No? (If yes, describe)Is it related to a Worker’s Compensation injury: Yes or No?Identify any other injury(s) to your spine, minor or major, that the doctor should know about:Have you had x-rays of your spine in the last 2 years: Yes or No?If yes, where were they taken?Past HistoryHave you suffered with any of this or a similar problem in the past?If yes, how many times?When was the last episode?How did it happen?Have you tried any other forms of treatment? Yes / NoIf yes, please state what type of treatment:Who provided it?How long ago?What were the results? Favorable / Unfavorable? Please explain.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 with a P for in the Past, C for Currently have and N for Never have had:Broken Bone Dislocations Tumors Rheumatoid Arthritis Fracture Cancer Disability Heart Attack Osteo Arthritis Diabetes Other serious conditions: List any Injuries, Surgeries, Childhood Diseases, Adult Diseases (How long ago?, Type of Care Received?, By Whom?Social HistorySmoking Cigars Pipe Cigarettes 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:SYMPTOMS QUESTIONNAIRESYMPTOMS OF SPINAL MISALIGNMENT QUESTIONNAIRE "The nervous system controls and coordinator all organs and structures of the human body." (Gray's Anatomy 29th ED., page 4). Misalignments vertebrae and disc may cause irritation to the nerves which could affect the area listed. Please help us help you by placing a check mark in the appropriate box under the "Possible Effects" column to indicate your symptoms.Neck RegionPossible Effects of a Malfunction Headaches Nervousness Insomnia Head colds High blood pressure Migraines Nervous breakdowns Amnesia Chronic tiredness Dizziness Sinus trouble Allergies Pain around eyes Earache Fainting spells Certain cases of blindness Crossed eyes Deafness Neuralgis Neuritis Acne or pimples Eczema Hay Fever Runny Nose Hearing Loss Adenoids Laryngitis Hoarseness Throat conditions such as sore throat or quinsy Stiff Neck Pain in upper arm Tonsilitis Chronic cough Croup Bursitis Colds Thyroid conditions Mid BackPossible Effects of a Malfunction Asthma Cough Difficulty breathing or shortness of breath Pain in lower arms and hands Functional heart conditions and certain chest conditions Bronchitis Pleurisy Pneumonia Congestion Influenza Gall bladder condition Jaundice Shingles Liver conditions Fever Blood pressure problems Poor circulation Arthritis Stomach troubles or nervous stomach Indigestion Heartburn Dyspepsia Ulcers Gastritis Lowered resistance Allergies Hives Kidney troubles Hardening of the arteries Chronic tiredness Nephritis Pyelitis Skin condition such as acne Pimples Eczema Boils Rheumatism Gaspains Certain types of sterility Low BackPossible Effects of a Malfunction Constipation Colitis Dysentery Diarrhea Some ruptures or hernias Cramps Difficult breathing Minor varicose veins Bladder troubles Menstrual troubles such as painful or irregular periods Miscarriage Bed wetting Impotency Change of life symptoms Many knee pains Sciatica Lumbago Difficult painful or too frequent urination Backaches Poor circulation in legs Swollen ankles, weak ankles and arches Cold feet Weakness in the legs Leg cramps PelvisPossible Effects of a Malfunction Sacro-iliac conditions Spinal curvatures Hermorrhoids (piles) Pruritis (itching) Pain at end of spine on sitting 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 [email protected]. 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 [email protected]. 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 [email protected]. 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*Date*Signature*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
