Adult Health Profile
As a Family Based Specialized Chiropractic Clinic, we focus on your ability to heal without drugs and surgery. Our goals
are; first, to address any current symptoms, and second, to offer you the opportunity of improved health through proper
spinal alignment and function.
Who May We THANK For Referring You? ____________________________________________________
Your Name: _________________________________ Gender: _______ DOB: (m/d/y) ________________
Full Address: _____________________________________________________________________________
Phone: h (______) __________________ w (______) __________________ c (______) _________________
Email: _________________________________________ Family MD:_____________________________
Name of Spouse/Partner/Children: ___________________________________________________________
Occupation: ______________________________ Employer: ______________________________________
Trauma History
Traumas in life such as car accidents, poor posture, work and sport injuries, poor sleep patterns and even the birth
process can create stress on the spine which in return can create symptoms, so please answer the following
questions to the best of your ability:
MVA Trauma
Date of Last Car Accident? __________________ Type of Collision? Front / Rear / Side / Rollover
Collision Speed? ☐Low (5-20kmh) ☐Med (21-60kmh) ☐ High (60+kmh)
Any Immediate Injuries? ___________________________________________________________________
Any Delayed Injuries? ______________________________________________________________________
Number of Car Accidents You’ve Been In? ___________________
Work Trauma
Date of Last Accident? ____________________ Type of Accident? _______________________________
Any Immediate Injuries? ___________________________________________________________________
Any Delayed Injuries? ______________________________________________________________________
Number of Work Accidents You’ve Been In? ___________________
Sport / Recreational Trauma
Date of Last Accident? ____________________ Type of Accident? _______________________________
Any Immediate Injuries? ___________________________________________________________________
Any Delayed Injuries? ______________________________________________________________________
Number of Sport / Rec Accidents You’ve Been In? ___________________
Home Trauma
Date of Last Accident? ____________________ Type of Accident? _______________________________
Any Immediate Injuries? ___________________________________________________________________
Any Delayed Injuries? ______________________________________________________________________
Number of Home Accidents You’ve Been In? ___________________
Please continue on to back of page…
Other Trauma
List Diagnosed Disease or Illness:_____________________________________________________________
Medications Currently Taking and Reason: ____________________________________________________
List Any Surgeries You Have Had: ___________________________________________________________
CURRENT CONDITION
Reason for consulting our office: _________________________________________________________
Rate Your Pain: 0☐
1☐
2☐
3☐
4☐
5☐
6☐
7☐
8☐
9☐
10☐ Analog Scale
Description of pain: Sharp / Dull / Ache / Shooting / Throbbing / Other____________________________
Does it: Come and go☐ / Stay Constant☐
Since the Problem Started, is it: The Same☐ / Worse / Better☐
What Makes it Worse? ______________________________________
What Makes it Better? ______________________________________
Does it Interfere with: Work☐ / Sleep☐ / Walking☐ / Sitting☐ / Leisure☐
Do you Currently Wear Custom Foot Orthotics? Yes☐ / No☐
If yes, when did you receive your last pair and from where? ______________________________________
Rate Your Stress Level (low / moderate / high): Occupational _____________ Personal _______________
Rate (Poor, Average, Good) Your: Diet_________ Exercise__________ Sleep__________ Health________
Please check (x) all symptoms you have ever had, even if they do not seem related to your current problem.
 Headaches
 Fainting
 Migraines
 Fatigue
 Dizziness
 Constipation
 Menstrual Pain
 Loss of Balance
 Diarrhea
 Menstrual
 Ringing in Ears
 Heartburn
 Buzzing in Ears
 Ulcers
 Neck Pain/Stiffness
 Loss of Taste
 Cold Sweats
 Chest Pain
 Loss of Smell
 Hot Flashes
 Pins & Needles in
 Loss of Hearing
 Fever
 Change in Vision
 Difficulty Sleeping
 Anxiety
 Difficulty
 Depression
 Mood Swings
 Irritability
 Muscle Tension
Urinating
 Difficulty
Defecating
 No control of
Bowel/Bladder
Irregularity
 Back Pain/Stiffness
 Low Back
Ache/Throb
 Pins& Needles in
Legs/Feet
 Numbness in
Legs/Feet
 Leg/Foot
Arms/Hands
Weakness
 Numbness in
 Cold Feet
Arms/Hands
 Arm/Hand
Weakness
 Cold Hands
 Hot/Painful Calves
 Tripping
FAMILY HEALTH PROFILE
ForeverYoung Chiropractic is not only interested in your health and well-being but the health and wellbeing of your loved ones. Please list any health conditions or concerns you may have about your:
Spouse/Partner: ___________________________________________________________________________
Children: _________________________________________________________________________________
Parents: __________________________________________________________________________________
Siblings: __________________________________________________________________________________
Friends: ___________________________________________________________________________
You’ve Come To The Right Place, We Look Forward To Helping You :)
Dr. Jason Young & Dr. Rebecca Huddleston
1111 Princess St. Kingston ON K7L2T1