Confidential Patient Information______________________________________________________________________
Inglewood Family Health:1217 10th Avenue SE, Calgary, AB,T2G 0W6
Date_____________Age________D.O.B(mo/day/year)________Sex____Marital Status___________________________
First & Last Names_____________________________Email________________________________________________
Street Address____________________________Appt #_____Province________Postal Code______________________
Phone(___)_________________Work Phone(___)____________________Cell (___)_____________________________
Occupation____________________Employer__________________Location___________________________________
Guardian/Spouse Full Name____________________________D.O.B(mo/day/year)______________________________
Occupation_____________________Employer__________________Location__________________________________
Have you seen a Chiropractor before?_________________________For What?_________________________________
How did you hear about our office?_____________________________________________________________________
Is your visit due to an accident? ____________yes____________no_____________when_________________________
Please list and explain your present complaints - _________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
List other doctor(s) seen for this condition:_______________________________________________________________
Personal Medical history (if any of the following are relevant to your medical history, please check the accompanying
box :)
Cancer
Muscular Dystrophy
Rheumatic Fever
Digestive Disorders
Polio
Multiple Sclerosis
Scarlet Fever
Sinus Trouble
Tuberculosis
Convulsions
Nervousness
Back Aches
Arthritis
Epilepsy
Asthma
Numbness
Heart Trouble
Concussion
Dizziness
High Blood Pressure
Diabetes
Hepatitis
German measles
Venereal Disease
Describe any operations you’ve had & the dates:__________________________________________________________
Have you been treated by a physician for any health concern in the last year?_____Yes_______No__________________
Describe_Condition___________________________________Date of last physical exam_________________________
Are you taking any medication?______Yes______No_What kind?_____________________________________________
Are you allergic to any medication?____Yes____No_What Kind?_____________________________________________
Are you pregnant?_____Yes_____No____N/A____________________________________________________________
Do you have insurance?___Yes___No___Company_______________I.D. No_________Policy Group No.____________
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I
understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that
any amount authorized to be paid directly to this office will be credited to my account upon receipt. I clearly understand and agree 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 and treatment, any fees for professional services rendered to me will be immediately due and payable unless prior
arrangements are made.
Patient’s ( Parent or Guardian’s) Signature______________________________Date:________________