Name First Last Birth Date* Date Format: MM slash DD slash YYYY Age*Gender Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Cell Phone #*Alternate Phone #Whom may we thank for referring you to this office?*BC Care Card Number or Personal Health Number:*EmployerOccupationMarital StatusSingleMarriedCommon-lawWidowNumber & Age of Children (Under 21)Number & Age of Children (Under 21)Name of Emergency ContactEmergency Contact Phone #Relationship to Emergency ContactHistory of ComplaintPlease identify the complaints that have brought you to our office (Please describe in detail):Primarily*SecondaryThirdFourthOn the scale of 0 to 10, with 10 being the worst pain, rate your above complaints:Primary or chief complaint:10987654321When did the problem(s) begin?*When is the problem at its worst?AMPMMid-dayLate PMHow long does it last?It is constantI experience it off and on during the dayIt comes and goes through the week.How did the injury happen?*Have the condition(s) ever been treated by anyone in the past?* Yes No How would you describe your symptoms?* Radiating Burning Dull Aching Numbness Sharp/Stabbing Tingling What relieves your symptoms?*What makes them feel worse?*List Restricted Activities*Is your problem the result of any type of accident?*Is it related to a Worker’s Compensation injury?*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 No Past HistoryHave you suffered with any of this or a similar problem in the past?* Yes No Have you tried any other forms of treatment?* Yes No Please identify any and all types of jobs you have tried in the past that have imposed any physical stress on you or your bodyIf you have ever been diagnosed with any of the following conditions, please indicate if it was in the Past, Currently, or Never have had:Broken BoneNeverCurrentlyPastDislocationsNeverCurrentlyPastTumorsNeverCurrentlyPastRheumatoid ArthritisNeverCurrentlyPastFractureNeverCurrentlyPastCancerNeverCurrentlyPastDisabilityNeverCurrentlyPastHeart AttackNeverCurrentlyPastOsteo ArthritisNeverCurrentlyPastDiabetesNeverCurrentlyPastOther serious conditionsPLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem (including auto or related accidents):InjuriesHow long agoType of Care ReceivedBy Whom SurguriesHow long agoType of Care ReceivedBy Whom Childhood DiseasesHow long agoType of Care ReceivedBy Whom Adult DiseasesHow long agoType of Care ReceivedBy Whom Do you also suffer from any of the following? HEADACHES ORTHOPEDIC PROBLEMS DIGESTIVE DISORDERS BEHAVIORAL PROBLEMS DIZZINESS NECK PROBLEMS POOR APPETITE ADD/ADHD FAINTING ARM PROBLEMS STOMACH ACHES RUPTURES/HERNIA SEIZURES/CONVULSIONS LEG PROBLEMS REFLUX MUSCLE PAIN HEART TROUBLE JOINT PROBLEMS CONSTIPATION GROWING PAINS CHRONIC EARACHES BACKACHES DIARRHEA SINUS TROUBLE POOR POSTURE HYPERTENSION ASTHMA SCOLIOSIS ANEMIA COLDS/FLU WALKING TROUBLE BED WETTING COLIC BROKEN BONES SLEEPING PROBLEMS FALL OFF BICYCLE FALL DOWN STAIRS Social HistorySmoking* Cigars Pipe Cigarettes None 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: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 office@vidachiropractic.ca. 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 office@vidachiropractic.ca. 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 office@vidachiropractic.ca. 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*Parent or guardian if under 18Signature*Please use your mouse or your trackpad to sign in the box above.
