NEW PATIENT APPLICATION FORM
WELCOME TO OUR CLINIC. Please fill out the following information
thoroughly. Please feel free to ask any questions if you need assistance. We
look forward to serving you.
_________________________________________________
Patient Signature:
__________________________________
Today’s Date:
Date: _______________
PATIENT APPLICATION SURVEY
Name: _______________________________________________ Birth Date (m/d/y): ______ / ______ / ______ Gender: M
F
Home Address: ______________________________________________ Home Phone: (
) _________________________
City, Province, Postal Code: ____________________________________ Work Phone: (
) _________________________
Email Address: ______________________________________________ Cell Phone: (
Occupation: _____________________________________________
) __________________________
Employer Name: ________________________________
How were you referred to the office? _____________________________________ Alberta Health Care No.: _______________
Marital Status: S M D W Common-Law ;
Spouse’s Contact Information: Work Phone: (
Spouse’s Name: _______________________________________________
) _____________________ Cell Phone: (
) ______________________
Spouse’s Occupation: ___________________________________ Employer: _______________________________________
Names and Ages of Children: ________________________________________________________________________________
PURPOSE OF THIS VISIT
Reason for this visit (Main Complaint):________________________________________________________________________
________________________________________________________________________________________________________
Is this related to an auto accident / work injury (WCB)?  Yes  No
If so, when: __________________________________
How did this above condition occur? __________________________________________________________________________
When did this condition begin (d/m/y)? __________/__________/__________
Did it begin:
Gradual
Sudden
How often do you get your symptom?
Progressive Over Time
Everyday 1x/wk
2x/wk
3x/wk
4x/wk
5x/wk
6x/wk
Bi-weekly Monthly
On a pain scale from 0-10 how would you rate your symptom? _____________
How long does the symptom last? ___________________________________________________________________________
What activities aggravate your symptoms? ____________________________________________________________________
Is there anything, which has relieved your symptoms?  Yes  No
Does the Pain Radiate into your:
Arms
Legs
Describe: ______________________________________
Does Not Radiate
If so, where? ____________________________
Have you had diagnostic tests (X-ray, MRI, CT) done for the above condition?  Yes  No If so, Which test? ______________
Are there any other symptoms associated with the above condition? _________________________________________________
Have you experienced this condition before?  Yes  No
If so, please explain: _____________________________________
Have you seen anyone for the above condition?  Yes  No
If so, Who? _________________________________________
What did they do? ______________________________ How did you respond? _______________________________________
Type of Pain:
Sharp
Dull
Ache
Burn
Throb
Spasm
Numb
Tingling
Shooting
Is this condition getting worse?  Yes  No
How often do you experience these symptoms throughout the day? :
Does complaint(s) interfere with (circle): Work
100%
75%
Sleep Hobbies Daily Routine
50%
25%
10%
Only with Activity
Explain: ___________________________
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EXPERIENCE WITH CHIROPRACTIC
Have you seen a Chiropractor before?  Yes  No
Who? ____________________________ When? __________________
Reason for visits: __________________________________________________________________________________________
How did you respond? _____________________________________________________________________________________
Did your previous chiropractor take before and after x-rays?
 Yes  No
Did you know posture determines your health?
 Yes  No
Are you aware of any of your poor posture habits?
 Yes  No
Explain: ________________________________________________________________________________________________
Are you aware of any poor posture habits in your spouse or children?  Yes  No
Explain: ________________________________________________________________________________________________
The most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively
moving downward weakening your whole body). Abnormal postural habits or distortions are the result of trauma or stress to the
body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will
cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. These misalignments are called
Subluxations (sub-lux-a-shuns). This results in a weakened and distorted posture. Postural distortions have many serious and
adverse effects on your overall health. Have you ever been told or felt like you carry your head forward, noticed a rounding of
your shoulders or a developing “hump” at the base of your neck?
(Please Circle) Yes
No
HEALTH CONDITIONS
Please list any medications or supplements (i.e. vitamins, minerals, herbs) you are currently taking and their purpose:
Please list any health conditions not mentioned:
Please list all past surgeries:
Please list all previous accidents and falls:
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Symptoms of Spinal Misalignment Questionnaire
`The nervous system controls and coordinates all organs and structures of the human body` (Gray`s
Anatomy, 29th Ed., p.4). Misalignments of spinal vertebrae and discs may cause irritation to the nerves,
which could affect the areas listed. Please help us help you by placing a check mark in the appropriate box to
indicate your symptoms.
Please Check Any Conditions That You Have
Previously or Are Currently Experiencing Below
Earache
Throat Conditions (Sore or Quinsy)
Hoarseness
Laryngitis
Eczema
Acne/Pimples
Blindness
Neuralgia
Deafness
Crossed Eyes
Adenoids
Runny Nose
Neuritis
Head Colds Dizziness
Headaches Nervousness Insomnia
Migraines
Nervous Breakdowns
High Blood Pressure
Chronic Tiredness
Sinus Trouble Allergies
Amnesia
Pain Around the Eyes
Stiff Neck
Croup
Upper Arm Pain
Colds
Bursitis
Asthma
Earache
Tonsilitis
Hay Fever
Chronic Cough
Boils
Thyroid Conditions
Pleurisy
Difficult Breathing or Shortness of Breath
Lower Arm and Hand Pain
Bronchitis
Pneumonia
Gall Bladder Conditions
Poor Circulation
Jaundice
Hardening of Arteries
Miscarriages
Ulcers
Kidney Conditions
Rheumatism
Dysentery
Varicose Veins
Impotency
Liver Conditions
Fevers
Indigestion
Stomach Conditions
Heartburn
Lowered Resistance
Constipation
Functional Heart Chest Conditions
Condition Influenza
Congestion
Shingles
Arthritis
Nervous Stomach
Cramps
Fainting Spells
Gastritis
Hives
Nephritis
Gas Pains
Pyelitis
Sterility
Diarrhea
Ruptures/Hernia
Bladder Conditions Sciatica
Menstrual Troubles (Painful or Irregular Periods)
Bed Wetting
Change of Life Symptoms
Knee Pain
Difficult, Painful, or Too Frequent Urination
Backaches
Swollen and Weak Ankles
Cold Feet
Weakness in Legs
Sacro-Iliac Conditions
Hemorrhoids (piles)
Weak Arches of Feet
Leg Cramps
Colitis
Spinal Curvatures
Pruritis (itching)
Pain at End of Spine on Sitting
Note: For further explanation of the conditions shown above, and
information about those not shown, ask your Chiropractor.
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TERMS OF ACCEPTANCE
When a person seeks chiropractic and rehabilitation health care it is essential for both parties to be working towards the same objective. Our main
goal as a Chiropractic facility is to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both
the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our
chiropractic method is a specific adjustment of the spine.
Health: According to the World Health Organization is ‘… a state of optimal physical, mental and social well-being, not merely the
absence of disease or infirmity’.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve
function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express it’s
maximum health potential.
Our overall goal is to eliminate the primary and secondary causes of disease process in the body, thus reducing the major interference to the
expression of the body’s innate wisdom and ability to heal. Our only method is specific adjustments to correct vertebral subluxation complexes
combined with rehabilitation procedures and lifestyle coaching.
NOTE: It is understood and agreed that the amount paid to Alberta Preventative Health Services for examination and x-rays is for that purpose
only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office. If the
patient needs their x-rays released from Alberta Preventative Health Services, consent must be signed and dated by the patient and authorized by
a staff member.
CONSENT TO CHIROPRACTIC TREATMENT
It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an
informed decision about proceeding with treatment.
Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such
as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise.
Benefits
Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves,
muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and
spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery.
Risks
The risks associated with chiropractic treatment vary according to each patient’s condition as well as the location and type of treatment.
The risks include:

Temporary worsening of symptoms – Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to
a few days.

Skin irritation or burn – Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy.
Skin irritation should resolve quickly. A burn may leave a permanent scar.

Sprain or strain – Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest,
protection of the area affected and other minor care.

Rib fracture – While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a
period of several weeks without further treatment or surgical intervention.

Injury or aggravation of a disc – Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can
degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have
a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may
not know their disc condition is worsening because they only experience back or neck problems once in a while.
Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc
condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. The consequences of disc
injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include
impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg
or arm function. Surgery may be needed.
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
Stroke – Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and
damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of
the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke.
Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery
in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain.
Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because
an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and
scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke.
The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as
paralysis or death.
Alternatives
Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without
treatment, or exercise with or without treatment.
Questions or Concerns
You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor’s
attention. If you are not comfortable, you may stop treatment at any time.
Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition.
DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR
I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature
of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby
consent to chiropractic treatment as proposed to me.
_______________________________________
Patient Signature
______________________________________
Witness Signature
_______________________________________
Patient Name (Print)
______________________________________
Witness Name (Print)
_______________________________________
Date
Please continue to next page…
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CONSENT TO CARE
Pregnancy Release
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his associates have my permission to perform an xray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
Date of last menstrual cycle: _____________________
_______________________________________
Signature
____________________
Date
Consent to Evaluate and Adjust a Minor Child
I, ______________________________________, being the parent of legal guardian of _____________________________________ have read
and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
_______________________________________
Signature
____________________
Date
Insurance Information
I clearly understand that all insurance coverage is an arrangement between my insurance carrier and me. This office does not accept assignment
of benefits, and therefore, all reimbursement activities are my own responsibility. The Doctor’s office will provide any necessary report or
required information to aid in insurance reimbursement of services. I certify that this office visit is not related to any personal injury or worker’s
compensation (WCB) case that is active or that has not been closed and finalized.
_______________________________________
Signature
(If under age 18 - Parent’s signature)
_____________________
Date
_______________________________________
Doctor Signature
_____________________
Date
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