Health Intake Form

Name

Email

Address

Date of Initial Visit

Phone Number

Date of Birth

Referred by

Physician Name

Allergies

Sports & Activities

Current Medications

Are you under medical care for any of the following:
Heart Conditions
Varicose Veins
Neck Injury
Osteoporosis
Cancer
Diabetes
Crohn's Disease
Nervous Disorders
High/Low Blood Pressure
Phlebitis/Circulatory Problems
Back Injury
Rheumatoid Arthritis
Kidney Disease
Asthma/Respiratory
Pelvic Inflammatory Disease
Whiplash
Fainting or Dizziness
Headaches or Migraine
Jaw or Ear Pain
Osteoarthritis
Skin Conditions
Fibromyalgia
Epilepsy
Other:

Have you received any of the following:
Physiotherapist
Chiropractor
Massage Therapist
Naturopath

Other:

Reason for Treatments:

Number/Duration of Treatments:

Have you had surgery in the past? Yes No

If yes, for what?

Have you had any fractures/sprains in the past? Yes No

If yes, where?

Have you had any serious illness in the past? Yes No

If yes, what?

Did the current injury result from a motor vehicle accident or workplace injury? Yes No

Have you had any of the following regarding your current condition:
Physician's Examination
X-ray
Other Diagnostic Tests

What relieves your pain?