Youth 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? ______________________________________________________
Name: ______________________________ Gender: _________ Age: _________ DOB: _______________
(Month / Day / Year)
Address: ______________________________________________________ Postal Code: _______________
Phone: (H) ________________________ (W)________________________ (C)_________________________
Email: ______________________________________
Family M.D _____________________________
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? ___________________
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? ___________________
Other Trauma
List Diagnosed Disease or Illness:_____________________________________________________________
Medications Currently Taking and Reason: ____________________________________________________
List Any Surgeries You Have Had: ___________________________________________________________
Please continue on to back of page…
Describe reason for consulting our office?
__________________________________________________________________________________
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: School☐ / Sleep☐ / Walking☐ / Sitting☐/ Leisure☐
On a scale of 1-10, describe your Pain, (1 = none, 10 = extreme) __________
On a scale of 1-10, describe your stress level (1=none, 10=extreme) School______ Personal______
On a scale of (1=Poor, 2=Avg, 3=Good) describe 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
 Fatigue
 Menstrual Pain
 Migraines
 Constipation
 Menstrual
 Dizziness
 Diarrhea
 Loss of Balance
 Heartburn
 Neck Pain/Stiffness
 Ringing in Ears
 Ulcers
 Chest Pain
 Buzzing in Ears
 Cold Sweats
 Pins & Needles in
 Loss of Taste
 Hot Flashes
Arms/Hands
 Loss of Smell
 Fever
 Loss of Hearing
 Difficulty Sleeping
 Change in Vision
 Difficulty
 Anxiety
 Depression
 Mood Swings
 Irritability
 Fainting
Urinating
 Difficulty
Defecating
 No control of
Bowel/Bladder
Irregularity
 Numbness in
Arms/Hands
 Arm/Hand
Weakness
 Cold Hands
 Pins& Needles
in Legs/Feet
 Numbness in
Legs/Feet
 Leg/Foot
Weakness
 Cold Feet
 Hot/Painful
Calves
 Tripping
 Muscle
Tension
 Back Pain/Stiffness
 Low Back
Ache/Throb
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