1. Most patients are referred to our clinic by a caring family member or friend.What made you decide to visit our clinic?
2. Research shows that your spine should be checked regularly.How many times have you consulted a chiropractor?
3. When was your last complete spinal examination?
4. Spinal tension causes decay and degeneration which results in grinding or cracking.Do you ever hear noises when you move your head or neck?
5. Spinal tension can make you feel like you need to twist, stretch or crack your neck or back.Do you ever feel the need to crack or pop your neck or lower spine?
6. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture? (Poor - 1 2 3 4 5 6 7 8 9 10 - Excellent)
YES NO
YES NO
1 2 3 4 5 6 7 8 9 10
Name:
Address:
Date of Birth: Occupation: Children:
I agree to be on Clinic Maintenant’s mailing list.
Home Phone: Work Phone: Cell Phone: E-mail Address:
City:
Status:
Province: Postal Code:
PART 1 - PATIENT CONTACT INFORMATION
PART 2 – GENERAL QuEsTIONs
WebsitePresentation Sign - Passing byFamily member or friendName:
PAGE 1/13
YES NO
1. Do you have a current health/life concern or symptom?
If YES, please describe:
When did it begin?
How and why did it manifest itself?
If NO, please describe the reason you are consulting our clinic and then skip directly to PART 4:
2. Is your problem a work-related accident or due to a road-accident?
If YES, please write down the date of the accident:
YES NO
7. Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days. (Low - 1 2 3 4 5 6 7 8 9 10 – High)
8. Prescription medication may cause serious side-effects, hide the severity of health problems and hinder the body’s ability to heal.What medication are you currently taking?
9. Car accidents and work-related injuries can cause serious damage to the spinal cord.Are you consulting our clinic because of a work-related injury or accident?
If YES, please write the date when it occurred :
1 2 3 4 5 6 7 8 9 10
PART 2 - GENERAL QuEsTIONs (CONT’D)
YES NO
PART 3 – YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE
PAGE 2 /13
3. Have you done anything about this concern or been given any advice or treatment for it?
If YES, describe what was done.
4. Have any other family members had the same or similar concerns?
If YES, what did they do about it?
Did it seem to work?
5. How aware are you of your symptom / concern in the morning when you get up? (0 = not at all / 3 = extremely aware)
6. How aware are you of your symptom / concern during the day? (0 = not at all / 3 = extremely aware)
7. How aware are you of your symptom / concern at the end of the day?(0 = not at all / 3 = extremely aware)
8. How are are you of your symptom / concern during the night?(0 = not at all / 3 = extremely aware)
9. Is there an activity that you do, during which you totally, or almost totally forget about this condition ?
10. Why do you think this is happening, or continues to happen to you?
11. Do you think this is the only reason?
If NO, what else may be the cause?
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
YES NO
YES NO
PART 3 - YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE (CONT’D)
YES NO
YES NO
PAGE 3 /13
12. Are you doing anyhting differently in your life because of this symptom / concern?
If YES, please describe:
13. If it were to go away tomorrow, how would your life be different?
14. Please grade how the concern / symptom affects the folllowing aspects of your functioning or quality of life: (0 = does not seem to affect me, 1 = slightly affects me, 2 = moderately affects me, 3 = extremely)
Work
Recreation
Rest / sleep
Social life
Walking
Sitting position
Exercising
Eating
Relationships
Comments:
15. If the situation didn’t change or evolve, how do you think it would affect your life in the next 5 years?
16. If we could work together to help you solve this problem, how would your life be different in the years to come ?
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
PART 3 - YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE (CONT’D)
YES NO
PAGE 4 /13
1. Your BirthDid your mother experience any problems during her pregnancy with you? Check all that apply: Falls Illness Difficult Not sure
Comments:
Was your birth...Check all that apply:
Traumatic
Cesarean
Breech
Forceps or suction
Cord around the neck
Prolonged
2. Falls Check all that apply, indicating age and year: Crib / Carriage Age:
Stairs Age:
On ice Age: From a tree Age:
3. General Physical TraumaCheck all that apply, indicating age and year:
Lost consciousness Age:
Use of crutches or a cane Age:
Broken bones or sprains (Describe): Age:
PART 4 - PHYsICAL sTREss HIsTORY
Very fast
Natural
Induced
Home
Hospital
Birthing Centre
Jungle gymsAge:
Skiing / SnowboardingAge:
Other falls (Please describe.)Age:
CombatAge:
Physical fightsAge:
SportsAge:
Extensive dental work / OrthodonticsAge:
Other (Describe):Age:
PAGE 5 /13
4. Accidents (big or minor, either as a driver or passenger) Check all that apply indicating age and year :
Car Age:
Motocycle Age:
Bus Age:
Train Age:
5. Daily ActivitiesCheck all that apply :
Sitting Standing Walking Desk work Phone Sports
6. Medical HistoryCheck all that apply, indicating age and year :
Hospitalisation - Reason? Age: Surgery - Why? Age:
Chemotherapy Age:
Radiation Age: Casts or corsets Age:
Spinal / Neck Brace Age:
PART 4 - PHYsICAL sTREss HIsTORY (CONT’D)
BikeAge:
AirplaneAge:
Other:Age:
Comments:
ExercisingComputer workWatching TVDriving / CommutingPlaying an instrument Reading for long periods
Mechanical workHeavy liftingContactsGlasses
Comments:
Corrective shoes, bars, liftsAge:
PhysiotherapyAge:
Spinal taps, injectionsAge:
Comments :
PAGE 6 /13
7. Have you or a family member ever suffered a serious illness?
8. Do you have a family doctor?
9. When was your last medical exam? Please write the date of the exam:
What were the results?
10. (For women.) Are you pregnant?
If YES, please indicate the number of weeks:
PART 4 - PHYsICAL sTREss HIsTORY (CONT’D)
YES NO
YES NO
PAGE 7/13
Alcohol Coffee / caffeine Processed food Artificial sweetners
Refined sugar Sodas Tap water
4. List all current and past medication and include reasons and length of time you were taking them.
5. Do you work with or have you worked with or ever been exposed to :
Chemicals Fumes Dust Powder / particles Smoke Other substances
6. Do you consume :
1. Birth stress
During your mother’s pregnancy, did she :Check all that apply :
Use prescription drugs Use non-prescription drugs Smoke
Consume alcohol / drugs I don’t know
2. During your birth, was your mother :Check all that apply :
Conscious Semi-conscious Unconscious
Given spinal anesthesia Given chemicals to alter or induce labour I don’t know
3. General Chemical stress : Are you taking or have you ever taken :Check all that apply :
Prescription drugs Over-the-counter drugs Antibiotics
Other drugs Tobacco
PAGE 8/13
PART 5 - CHEMICAL sTREss HIsTORY
7. Describe your diet :
PAGE 9/13
1. Were you incubated or isolated after birth?
YES NO
2. Were you :
Bottle-fed Nursed Both
3. Past General Emotional Trauma
Check all that apply and note the severity (mild, moderate or extreme) :
PAST PRESENT MILD MODERATE EXTREME
Childhood
Personal relationship
Change of job / career
School
Divorce / separation
Change of lifestyle
Recreational
Work-related
Commuting
Loss of loved-one
Parents’ divorce
Abuse
Family
Financial
Stress of being sick / ill
Comments :
PART 6 - EMOTIONAL sTREss HIsTORY
PAGE 10 /13
1. How would you rate your emotional mental health?
Excellent Good Fair Poor Getting better Getting worse
2. How would you rate your overall quality of life?
Excellent Good Fair Poor Getting better Getting worse
3. Have you pursued other avenues of growth, healing or personal development? Check all that apply :
Chiropractic Acupuncture Massage / Bodywork Homeopathy Psychotherapy Ayurvedic Medecine
Osteopathy Physical Therapy Aromatherapy Energy Work Rebirthing Sound / Light Therapy
4. What aspects of your life do you like, bring you joy or help you to feel better about yourself?
5. What particular factors or elements about your life experiences (family, work, recreational, past injuries, genetics, dietary programs, exercises, outlook, etc.) do you feel impair your opportunity to experience full health and wellness?
6. Which of the following do you practice regularly?
Exercise - Times per week : Yoga - Time per week : Chi Gong - Times per week :
Movement / Dance - Times per week : Meditation - Times per week : Prayer - times per week :
7. List any herbs, nutritional supplements or natural remedies you regularly take:
8. When stressed, how do you “centre” yourself or “re-group”?
PART 7 - LIFEsTYLE PROFILE
PAGE 11/13
2. Mental / Emotional state Rate the following questions in terms of frequency :
Feelings of distress when pain is present
Negative or critical feelings about yourself
Moodiness, temper flare-ups or outbursts of anger
Feelings of depression, lack of interest
Over-reacting to life stresses
Being overly worried about small things
Feelings of vague fears or anxiety
Difficulty thinking or concentrating or indecisiveness
Difficulty falling asleep or staying asleep
Experience of recurring thoughts or dreams
PART 8 - WELLNEss AND QuALITY OF LIFE suRVEY (CONT’D)
NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY
1. Physical state How often do you experience the following symptoms :
Physical pain (neck/back ache, sore arms/legs, etc.)
Feeling of tension, stiffness or lack of flexibilty
Fatigue, lack of energy
Colds, flu
Headaches
Heartburn, indigestion
Nausea, constipation
Menstrual discomfort
Allergies, skin rashes
Dizziness, light-headedness
Accidents, near accidents, fall-ing or tripping
Ease of recovery from injury
Restricted or shallow breathing
NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY
PAGE 12 /13
4. Life Enjoyment Rate the following statements with respect to frequency :
PART 8 - WELLNEss AND QuALITY OF LIFE suRVEY (CONT’D)
Openness to guidance from your ‘inner voice’ or intuition
Experience of peace, relaxa-tion, ease or well-being
Presence of positive thoughts about yourself
Interest in maintaining a healthy lifestyle
Feeling of being open, aware and connected when relating to others
Confidence in your abilty to deal with adversity
Level of compasison for and acceptance of othersExperience feelings of joy or happiness
Experiencing gratitude
Satisfaction with your sex-lifeSatisfaction with your leisure activitiesTime dedicated to the things that you like to do
NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY
3. stress Evaluation Evaluate your stress with respect to the following :
Family
Significant Other
Physical Health
Finances
Sex Life
Work or School Coping with daily problems
NONE sLIGHT MODERATE ExTENsIVECONsIDERABLE
PAGE 13 /13
5. Overall Quality of LifeEvaluate your feelings with respect to your quality of life :
Your personal life
Your wife/husband or“significant other”
Your romantic life
Your job
Your co-workers
The work you actually do
Handling problems in your life
What you are actually ac-complishing in your life
Your physical appearance - the way you look
Your abilty to adapt to change in your life
Overall contentment with your life
uNHAPPY MAINLY DIssATIsFIED MOsTLY MIxED HAPPYsATIsFIED