Fairway Chiropractic Centre - Top Rated Chiropractor Kitchener, ON

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? :

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 :

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

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 :

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

In good health? :

Yes

Father living?:

Yes

In good health? :

Yes

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 :

CONDITION ARTHRITIS :

FATHER AGE :

MOTHER AGE:

SPOUSE AGE :

SIBLINGS 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 :

CONDITION BACK TROUBLE :

FATHER AGE:

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE :

CHILDERN AGE :

CONDITION BED WETTING :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE:

CHILDERN AGE :

CONDITION BURSITS :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS 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 :

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:

CONDITION DIABETES :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE :

CHILDERN AGE :

CONDITION DIARRHEA :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS 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 :

CONDITION HEADACHES :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS 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 :

CONDITION INDIGESTION :

FATHER AGE:

MOTHER AGE:

SPOUSE AGE :

SIBLINGS AGE :

CHILDERN AGE :

CONDITION INSOMNIA :

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE:

CHILDERN AGE :

CONDITION KIDNEY PROBLEM

New Field :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE :

CHILDERN AGE :

CONDITION SINUS TROUBLE:

FATHER AGE :

MOTHER AGE :

SPOUSE AGE :

SIBLINGS AGE :

CHILDERN AGE :

OTHER :

ADDITIONAL COMMENTS :

Adult Consultation History

Initial Child & Adolescent Questionnaire

HEALTH QUESTIONNAIRE

FAMILY HEALTH HISTORY

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