Patient Entrance Form - Your Pickering Chiropractors

Skip to content

905-831-3939
info@yourpickeringchiropractors.ca

905-831-3939
info@yourpickeringchiropractors.ca

New patient paperwork

BOOK APPOINTMENT

Home
Our Team
Services
Common Conditions
Blog
Contact
- New Patient Paperwork Form

Home
Our Team
Services
Common Conditions
Blog
Contact
- New Patient Paperwork Form

Home
Our Team
Services
Common Conditions
Blog
Contact
- New Patient Paperwork Form

Home
Our Team
Services
Common Conditions
Blog
Contact
- New Patient Paperwork Form

Patient Entrance Form

Step 1 of 5

20%

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City Province Postal Code

Primary Phone(Required)

Alternate Phone

Marital Status(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Email(Required)

Occupation(Required)

Employer Address

Street Address Address Line 2 City Province Postal Code

Employer Phone

Spouse's Name

Children

Emergency Contact

Phone

How did you hear about our office?(Required)

Sign

Website

Friend/Family

Doctor/Referral

Other

CLAIM WILL BE MADE AGAINST

Work related injury/accident (WSIB)

Yes (if yes, see attached)

No

Recent motor vehicle accident (MVA)

Yes (if yes, see attached)

No

Extended Health Care Plan (EHC)

Yes (if yes, see attached)

No

EHC Company Name

EHC Plan/Contract#

EHC File/Certificate#

PRIOR CHIROPRACTIC CARE

Name

Phone

X-rays taken

Yes

No

Date

MM slash DD slash YYYY

Results

Excellent

Good

Fair

Poor

MEDICAL DOCTOR

Name

Phone

Address

Street Address Address Line 2 City Province Postal Code

Date of last appointment

MM slash DD slash YYYY

Date of last physical

MM slash DD slash YYYY

Reason for consulting this office(Required)

Expectations

Areas of pain or unusual feeling

Head

Numbness

Pins & needles

Burning

Aching

Stabbing

Neck

Numbness

Pins & needles

Burning

Aching

Stabbing

Shoulders

Numbness

Pins & needles

Burning

Aching

Stabbing

Arms

Numbness

Pins & needles

Burning

Aching

Stabbing

Hands

Numbness

Pins & needles

Burning

Aching

Stabbing

Chest

Numbness

Pins & needles

Burning

Aching

Stabbing

Stomach

Numbness

Pins & needles

Burning

Aching

Stabbing

Waist

Numbness

Pins & needles

Burning

Aching

Stabbing

Thighs

Numbness

Pins & needles

Burning

Aching

Stabbing

Knees

Numbness

Pins & needles

Burning

Aching

Stabbing

Quads

Numbness

Pins & needles

Burning

Aching

Stabbing

Feet

Numbness

Pins & needles

Burning

Aching

Stabbing

Back

Numbness

Pins & needles

Burning

Aching

Stabbing

Pelvis/gluteal region

Numbness

Pins & needles

Burning

Aching

Stabbing

Have you ever had the following?

Aneurysm

Ostheoporosis

Diabetes

Arthritis

Respiratory conditions

Epilepsy

Cancer

Strokes

Allergies

Heart conditions

Hepatitis

Nerves

Fatigue

Polio

Sleeping difficulty

Pneumonia

Pleurisy

Asthma

V.D.

Psoriasis

HIV

Sinus conditions

Childhood conditions had, please check

Measles

Mumps

Chicken pox

Whooping cough

Scarlet fever

Diphtheria

Rheumatic fever

Typhoid fever

Ear infections

Tubes in ears

Chronic illness

PATIENT PAST HISTORY FORM

O = Occasional F - Frequent C = Constant

Allergy

Occasional

Frequent

Constant

Convulsions

Occasional

Frequent

Constant

Chills

Occasional

Frequent

Constant

Dizziness

Occasional

Frequent

Constant

Fevers

Occasional

Frequent

Constant

Headache

Occasional

Frequent

Constant

Fainting

Occasional

Frequent

Constant

Loss of sleep

Occasional

Frequent

Constant

Depression

Occasional

Frequent

Constant

Neuralgia

Occasional

Frequent

Constant

Numbness

Occasional

Frequent

Constant

Nervousness

Occasional

Frequent

Constant

Loss of weight

Occasional

Frequent

Constant

Sinus infections

Occasional

Frequent

Constant

Tremors

Occasional

Frequent

Constant

Night Sweats

Occasional

Frequent

Constant

Enlarged glands

Occasional

Frequent

Constant

Tonsilitis

Occasional

Frequent

Constant

Sore throats

Occasional

Frequent

Constant

Enlarged thyroid

Occasional

Frequent

Constant

Gum trouble

Occasional

Frequent

Constant

Far sighted

Occasional

Frequent

Constant

Failing vision

Occasional

Frequent

Constant

Eye pain

Occasional

Frequent

Constant

Near sighted

Occasional

Frequent

Constant

Hoarseness

Occasional

Frequent

Constant

Nasal obstruction

Occasional

Frequent

Constant

Hay fever

Occasional

Frequent

Constant

Nose bleeds

Occasional

Frequent

Constant

Skin

Hives or allergy

Occasional

Frequent

Constant

Bruise easily

Occasional

Frequent

Constant

Dryness

Occasional

Frequent

Constant

Boils

Occasional

Frequent

Constant

Varicose veins

Occasional

Frequent

Constant

Skin rash

Occasional

Frequent

Constant

Itching

Occasional

Frequent

Constant

Genitourinary

Loss control urine

Occasional

Frequent

Constant

Frequent urination

Occasional

Frequent

Constant

Blood in urine

Occasional

Frequent

Constant

Bed wetting

Occasional

Frequent

Constant

Pus in urine

Occasional

Frequent

Constant

Prostate trouble

Occasional

Frequent

Constant

Painful urination

Occasional

Frequent

Constant

Kidney infection

Occasional

Frequent

Constant

Smell of urine

Occasional

Frequent

Constant

Muscle & Joint

Low back pain

Occasional

Frequent

Constant

Hernia

Occasional

Frequent

Constant

Foot trouble

Occasional

Frequent

Constant

Arthritis

Occasional

Frequent

Constant

Pain between shoulders

Occasional

Frequent

Constant

Neck stiffness

Occasional

Frequent

Constant

Neck pain

Occasional

Frequent

Constant

Pain or numbness in

Hips

Occasional

Frequent

Constant

Hands

Occasional

Frequent

Constant

Arms

Occasional

Frequent

Constant

Shoulders

Occasional

Frequent

Constant

Feet

Occasional

Frequent

Constant

Ankles

Occasional

Frequent

Constant

Knees

Occasional

Frequent

Constant

Legs

Occasional

Frequent

Constant

Swollen joints

Occasional

Frequent

Constant

Sciatica

Occasional

Frequent

Constant

Painful tail bone

Occasional

Frequent

Constant

Respiratory

Throat phlegm

Occasional

Frequent

Constant

Spitting blood

Occasional

Frequent

Constant

Difficulty breathing

Occasional

Frequent

Constant

Chest pain

Occasional

Frequent

Constant

Chest Wheezing

Occasional

Frequent

Constant

Cardiovascular

Hardening of arteries

Occasional

Frequent

Constant

Swelling of ankles

Occasional

Frequent

Constant

Slow heart beat

Occasional

Frequent

Constant

Rapid heart beats

Occasional

Frequent

Constant

Poor circulation

Occasional

Frequent

Constant

Pain over heart

Occasional

Frequent

Constant

Low blood pressure

Occasional

Frequent

Constant

High blood pressure

Occasional

Frequent

Constant

Eyes, ears, nose & throat

Dental decay

Occasional

Frequent

Constant

Deafness

Occasional

Frequent

Constant

Crossed eyes

Occasional

Frequent

Constant

Colds

Occasional

Frequent

Constant

Ear noises

Occasional

Frequent

Constant

Ear discharges

Occasional

Frequent

Constant

Ear aches

Occasional

Frequent

Constant

Asthma

Occasional

Frequent

Constant

Gastrointestinal

Colitis

Occasional

Frequent

Constant

Liver trouble

Occasional

Frequent

Constant

Burping or gas

Occasional

Frequent

Constant

Excessive hunger

Occasional

Frequent

Constant

Difficult digestion

Occasional

Frequent

Constant

Diarrhea

Occasional

Frequent

Constant

Constipation

Occasional

Frequent

Constant

Colon trouble

Occasional

Frequent

Constant

Hermorrhoids

Occasional

Frequent

Constant

Stomach pain

Occasional

Frequent

Constant

Gall bladder trouble

Occasional

Frequent

Constant

Distension of abdomen

Occasional

Frequent

Constant

Nausea

Occasional

Frequent

Constant

Poor appetite

Occasional

Frequent

Constant

Jaundice

Occasional

Frequent

Constant

Intestinal worms

Occasional

Frequent

Constant

Vomit blood

Occasional

Frequent

Constant

Vomiting

Occasional

Frequent

Constant

HABITS OF LIFESTYLE

Do you consume alcohol?(Required)

Yes

No

Do you smoke?(Required)

Yes

No

Do you exercise?(Required)

Yes

No

Exercise indoor activities

How many hours/week?

Exercise outdoor activities

Rate your sleep, hours per night

4-6

6-8

8-10

12+

Do you wake rested?

Yes

No

Rate your appetite

Poor

Fair

Medium

Good

Excellent

Rate your diet

Poor

Fair

Medium

Good

Excellent

Do you eat regularly

Breakfast

Lunch

Dinner

Do you eat per day

1 meal

2 meals

3 meals

4 meals

More than 4 meals

Date of last dental examination

MM slash DD slash YYYY

Falls and accidents - list

Surgery and operations - list

Do you take vitamins and minerals?(Required)

Yes

No

List

Have you ever been knocked unconcious?(Required)

Yes

No

Don't know

If yes, for how long and when?

List any medications or drugs you are currently taking

Have you previously been hospitalized?(Required)

Yes

No

Please list

Any family health conditions or problems?(Required)

Yes

No

Please list

Do you suffer from neck pain?(Required)

No

Yes

If yes, please fill out these questions regarding your neck pain. Click on "ADD ENTRY"

SECTION 1 - PAIN INTENSITY	Actions
	Edit Delete
There are no Entries.

Maximum number of entries reached.

Do you suffer from back pain?(Required)

No

Yes

If yes, please fill out these questions regarding your back pain. Click on "ADD ENTRY"

SECTION 1 - PAIN INTENSITY	Actions
	Edit Delete
There are no Entries.

Maximum number of entries reached.

PLEASE NOTE - In order to diagnose your condition(s) and recommend treatments options, physical examinations will be performed to reproduce your primary complaint and, as such, may temporarily aggravate your symptoms. By signing this form, you are confirming the accuracy of your medical history and consent to physical examinations as required to diagnose your current and future symptoms.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Chiropractors are experts in the diagnosis and treatment of injuries or conditions related to your nerves, muscles, bones and joints and how these conditions may impact your overall health and ability to work, perform and enjoy life.

BOOK APPOINTMENT

Contact us

ADDRESS

1885 Glenanna Rd.
Suite 107
Pickering ON L1V 6R6

phone

E-mail

info@yourpickeringchiropractors.ca

Our Links

Chiropractic
Acupuncture
Massage Therapy
Custom Orthotics
MED-X Laser
Ultrasound Therapy
TENS
Therapeutic Exercise & Rehabilitation Guidance

Copyright 2021 • All Rights Reserved • Your Pickering Chiropractors • Web Development: www.RectifyOnlineMarketing.com