Patient Introduction: Age 5 - 17
Child’s Name:
____ ____ DOB: ______________________________
Alberta Health care #: _________________________ Mother’s Name: _____________________
Father’s Name: __________________ Do you have health care custodial rights?  YES  NO
Whom can we thank for referring you to our office? ____________________________________
Do you have Blue Cross Insurance?  YES  NO
Policy #: ___________________________ Group #: ____________________________________
Address:
____________________________________________________
City: ______________________________ Province: _________ Postal Code: ________________
Phone #:___________________________ E-mail: ______________________________________
Num. of siblings: ___________ Child’s Weight: ____________ Child’s Height: _______________
Type of Birth:  Normal Vaginal  Forceps  Cesarean
Hospital: _______________________________________________________________________
Problems during pregnancy:
Problems during labor or delivery:
Length of labor: __________ Congenital abnormalities or defects: ________________________
Number of hours of sleep per night: ___________ Quality of sleep:  Good  Fair  Poor
Pediatrician / Family Medical Doctor:
______
Date of last visit to Medical Doctor:
Purpose:
Vaccination history:
Has your child ever been treated on an emergency basis?
What is the purpose of your appointment?
Date symptoms appeared?
_________ What area? (Please circle) Mid Back Low Back Hips
Other: _________________________________________________________________________
How did it start?  Gradually  Suddenly
How would you describe the pain? Sharp Dull Achy Burning Stabbing Deep Shooting
How intense is the pain?  Mild  Moderate  Severe
Does your condition come and go or is it constant? _____________________________________
What aggravates your condition? (Please circle) Activity Rest Lifting Occupation Bending
Turning Stress Other: __________________________________________________________
What relives your condition? (Please circle) Activity Rest Ice Heat Standing Sitting
Lying Down Other:_____________________________________________________________
Is this condition interfering with your:  Quality of Life  Work  Sleep
Other: _________________________________________________________________________
Other Doctors seen for this condition?
Have you been treated for any health condition in the last year?  YES  NO
Describe:
What over-the-counter medications are you taking? ____________________________________
What prescription medications are you taking?
Past History
What operations have you had? When?
Have you ever been hospitalized?  YES  NO Serious Illness: __________________________
Have you ever had any bad accidents or falls?  Yes  No
If so, when? __________________
Broken/Fractured bones?  Yes  No Which ones?
Have you ever been under Chiropractic care?  Yes  No
Chiropractor’s Name:
__________________ Last Adjustment date: ______________
Childhood Diseases:  Chickenpox Rubella  Mumps  Measles
 Whooping Cough
Other: __________________________________________________________________________
Are You Suffering From or Have You Ever Suffered From:
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Allergy
Dizziness
Fatigue
Headache
Loss of sleep
Ulcers
Nervousness / Depression
Numbness
Arthritis
Hyperactivity
Foot trouble
Low back pain
Neck pain or stiffness
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Tingling or numbness in:
Shoulders
 Hips
Arms
 Legs
Elbows
 Knees
Hands
 Feet
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Please shade or circle all areas of complaint.
Poor posture
Sciatica
Spinal curvatures
Swollen joints
Constipation
Diarrhea
Difficult digestion
Hemorrhoids
Nausea
Asthma
Colds
Deafness
Ear noises
Enlarged thyroid
Eye pain
Failing vision
Venereal disease
Heart disease
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Tuberculosis
Bruise easily
Hay fever
Nosebleeds
Sinus Infection
High blood pressure
Low blood pressure
Pain over heart
Poor circulation
Rapid heart beat
Slow heart beat
Anemia
Stroke
Chest pain
Difficult breathing
Pleurisy
Spitting
Swelling of ankles
Cancer
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Itching
Varicose veins
Bed-wetting
Frequent urination
Kidney infection or stone
Stomach Aches
Cramps or backache
Excessive menstrual flow
Behavioral Problems
Irregular cycle
Chronic Ear Aches
Growing Pains
Diabetes
Polio
Aids / HIV positive
Hypoglycemia
Chronic fatigue syndrome
Psoriasis / Eczema
Is there any other information?
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AUTHORIZATION FOR CARE OF A MINOR
The Informed Consent must disclose, to the patient or the guardian of a minor patient, the
nature of the proposed treatment or procedure and any potential risks including those that may
be of a special or unusual nature.
I HEREBY AUTHORIZE THIS CLINIC AND ITS DOCTOR(S) TO ADMINISTER CARE AS THEY DEEM
NECESSARY TO MY SON / DAUGHTER / WARD (UPON APPROVAL OF PARENT OR GUARDIAN)
Signed:
Witnessed:
Date: ___________________
I understand that all services rendered to me are charged directly to me and that I am
personally responsible for payment. I also understand that if I suspend or terminate my care,
any fees for professional services rendered will be immediately due and payable.
We request 24 hours noticed of a cancelled visit.
I understand that Chiropractic does not treat the disease or symptoms but uses them to
ascertain where the specific adjustment(s) are needed. Chiropractic only attempts to adjust
vertebrae, restoring the nerve impulses to the involved tissue, thus allowing the body it’s best
chance of healing itself. I give the doctors and assistants at Complete Health Chiropractic and
Massage full permission to render care to myself and/or my family.
Date:
Signature:
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