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Initial Consultation Forms
Online form
Adult Consultation History
Your Name:
Phone:
Address:
City :
Postal Code :
Birth Date :
Email Address:
Spouse's Name:
Extend Health Care Co :
Your Occupation :
Employer :
Employer Address :
Phone :
Madical Doctor :
Phone :
How did you hear about our clinic? :
Your Main Complaint :
Any Other Complaint :
How long you have suffered with this problem? :
What have you tried to do to get rid of this problem that DID NOT work? :
When your problem is at worst, how does it make you feel? :
How does this problem interface with the following areas of your life? :
WORK :
FAMILY :
HOBBIES :
LIFE :
What did you do that makes this problem worse? :
What gives you some temporary relif? :
What is the Pattern of this problem? :
Constant:
Intermediate
Occasional:
cylic:
How did it start? :
Are you on any type of madication?:
Please list all :
Could yor problem have been cased by an injury at work? :
Date of Accident :
Any difficuilties from this? :
Is there any other information like to know? :
On a scale of 1 to 10,with 10 being the higest rate your commitment in helping us solve this problem :
Thank you for contacting us.
We will get back to you as soon as possible
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Online Form
Initial Child & Adolescent Questionnaire
Name:
Phonel:
Address:
City:
Postal Code :
Birth Date :
How did you hear about our clinic? :
Medical Doctor :
Phone :
Your Child's Main Complaint :
Mom's Name :
Dad's Name :
Mainly for Moms :
1.Tell us about your pregnancy;
Did you carry to Full term? :
Describe any complications and when they occurred :
2.Tell us about your delivery and birth of this child :
Did you use a midwife? :
Hospital? :
Obstetrician? :
Did you have a C-Section :
Were forceps used? :
Vacuum Extraction? :
Were you induced? :
Did you have an Epidural? :
Was it a difficult Birth? :
What was the baby's APGAR Score? :
At 5 minutes? :
3.Tell us more :
Did you breastfeed ?:
How long? :
What formula after? :
Did you consume alcohol during your pregnancy? :
How much? :
Did you smoke? :
How much? :
How long? :
Did you take any madicine during your pregnancy? :
For what? :
What Type? :
Any exposures to ultrasound? :
How many? :
4. As a baby/toddler.(birth to 4 years), did any of the following occur? :
Fall from a change Table :
Frequent crying spells :
Tumble down stairs :
Frequent fevers :
Fall out of crib :
Frequent bouts of dirrnea :
Involved in a car accident :
constipiation :
Fall of playground equipment :
Sleeping problems :
Play in a jolly jumper :
Frequent colds :
Frequent ear infactions :
Colic :
Tonsilities :
Did not gain weight:
Reaction of vaccination :
Other:
Please Explain the above :
5.As a young child,(5 to 12 years),did any of the following occur? :
Fall from a tree :
Bed wetting :
Fall of a bicycle :
Hyperactivity/Autism :
Fall of Playground Equipment :
Learning difficulties :
Sports accident:
Allergies:
Stomach pain:
Leg/Knee pain :
Scoliosis :
Other :
Please explain the above :
6. Tell us about any vaccination your child has had :
Any reaction to any of these :
Were you told that you had a choice in vaccinating your child? :
Yes
No
7. As a child or adolescent has your child experinced any of these :
Headaches :
Numbness in arms/hands :
Foot/ankle/knee pains:
Dizziness :
Arm/wrist pain :
Tingling in arms/legs :
Ringing in ears :
Sleeping Problems :
Neck/back pain:
Asthma :
Allergies :
Shoulder Pain :
Hyperactivity :
Fatigue :
Other :
8.Which of the following problem you have checked off is the worst :
Is this problem :
Constant
Intermittent
Occasional
Cylic
9. How long has it persisted? :
10.When it is at its worst,how does it make your child feel? :
11.What have you done about it that has NOT worked?:
12.What make it worse? :
13.What effect does this problem have of your child's body function? :
14.Describe any hospital stay? :
15.List any medications your child is currently taking :
To summarize,what is your purpose for this appointment :
Is there anything else you feel we should know :
Thank you for contacting us.
We will get back to you as soon as possible
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HEALTH QUESTIONNAIRE
Name:
Date:
Please indicate For each question below your experiance by use of one of the following codes:
(Codes) 1-NEVER had 2-PERVIOUSLY had 3-PERESENTLY have:
MUSCULO-SKELETAL SYSTEM CODE :
low back problem :
Pain between shoulders:
Neck problem :
Arm problem :
Leg problem:
Swollen joints :
Painful joints:
Stiff joints:
Sore muscles :
Weak muscles :
Walking problem :
Broken bones :
GENITO-URINARY SYSTEM CODE :
Bladder trouble:
Excessive urine :
Scanly urination :
Painful urination :
Disclored urine :
FEMALE CODE :
Vaginal discharge :
Vaginal Bleeding :
Vaginal pain :
Breast pain :
Lumps on breast :
GESTRO-INTESTINAL SYSTEM CODE :
Poor appetite :
Exceassive hunger:
Difficult chewing :
Difficult swallowing :
Excessive thirst :
Nauses:
Vomiting food :
Vomiting Blood :
Abdominal pain :
Constipation :
Black stool :
Bloody stool:
Liver trouble :
Gall bladder problem :
Weight problem:
NERVOUS SYSTEM CODE :
Numbness :
Paralysis:
Dizziness :
Fainling:
Headache :
Muscle jerking :
Forgetfulness :
Confusion :
Depression :
CARDIO-VASCULAR-RESPIRATORY CODE :
Chest pain :
Difficult breathing :
Coughing phiegm:
Coughing Blood :
Rapid heartbeat :
Blood pressure problem:
Heat problem :
Lung problem :
Varicose veins :
EYE,EAR,NOSE AND THROAT CODE :
Eye strin :
Eye inflammation :
Vision problem :
Ear pain :
Hearing loss :
Ear discharge:
Nose pain :
Nose bleeding :
Nose discharge :
Difficult breathing thru nose :
Sore gums :
New Field :
Sore mouth :
Hoarsenees :
Difficuilt Speach :
Childhood diseeses :
Complications :
Prior surgery :
Medication presently taking :
Pervious accidents :
Mother living? :
Yes
No
In good health? :
Yes
No
Father living?:
Yes
No
In good health? :
Yes
No
Thank you for contacting us.
We will get back to you as soon as possible
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FAMILY HEALTH HISTORY
PATIENT NAME:
DATE:
Please review the diseases and conditions listed below and indicate those that are current health problem of a family member by
the designation C under his or her column. The designation P should be used to indicate a past problem.Leave blank those spacses that do not apply.:the designation C under his or her column. The designation P should be used to indicate a past problem.Leave blank those spacses
that do not apply :
Condition ADHD :
FATHER AGE :
MOTHER AGE:
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE:
CONDITION ALLERGIES :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION ARTHRITIS :
FATHER AGE :
MOTHER AGE:
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION ASTHMA :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CONDITION AUTISM :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION BACK TROUBLE :
FATHER AGE:
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION BED WETTING :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE :
CHILDERN AGE :
CONDITION BURSITS :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION CANCER :
FATHER AGE:
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE :
CHILDERN AGE:
CONDITION CHEST PAIN:
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE:
CONDITION COLIC :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION COLITIS :
FATHER AGE:
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE :
CHILDERN AGE:
CONDITION CONSTIPATION :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE:
CHILDERN AGE:
CONDITION DIABETES :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION DIARRHEA :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE:
CHILDERN AGE:
CONDITION EAR INFECTION :
FATHER AGE:
MOTHER AGE :
SPOUSE AGE :
CHILDERN AGE :
SIBLINGS AGE :
CHILDERN AGE :
CONDITION EPILEPSY :
FATHER AGE :
MOTHER AGE :
SPOUSES AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION HEADACHES :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE :
CHILDERN AGE :
CONDITION MIGRAINES :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE:
CHILDERN AGE :
CONDITION HEART TROUBLE :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION INDIGESTION :
FATHER AGE:
MOTHER AGE:
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION INSOMNIA :
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE:
CHILDERN AGE :
CHILDERN AGE :
CONDITION KIDNEY PROBLEM
New Field :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
CONDITION SINUS TROUBLE:
FATHER AGE :
MOTHER AGE :
SPOUSE AGE :
SIBLINGS AGE :
CHILDERN AGE :
CHILDERN AGE :
OTHER :
ADDITIONAL COMMENTS :
Thank you for contacting us.
We will get back to you as soon as possible
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Top Rated Chiropractor Kitchener
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