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The Holistic Wellness Centre
The Holistic Wellness Centre
The Holistic Wellness Centre
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    • Meet Your Team
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  • Chiropractic
    • New Patients
      • How to Get Started
      • Adult New Patient Form
      • Child New Patient Form
    • Chiropractic FAQ
    • Quantum Neurology
    • Quantum Neurological Reset Therapy – QNRT
    • Pediatrics & Pregnancy
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      • Small Animal Intake Form
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  • New Patients
    • How to Get Started
    • Adult New Patient Form
    • Child New Patient Form
  • Blog
  • Contact
  • Directions
  • (519) 966-7880
  • Home
  • About Us
    • Meet Your Team
    • Virtual Office Tour
  • Chiropractic
    • New Patients
      • How to Get Started
      • Adult New Patient Form
      • Child New Patient Form
    • Chiropractic FAQ
    • Quantum Neurology
    • Quantum Neurological Reset Therapy – QNRT
    • Pediatrics & Pregnancy
  • Additional Services
    • Animal Chiropractic
      • Animal FAQ
      • Small Animal Intake Form
    • Registered Massage Therapy
    • Acupuncture
    • Ayurveda
    • Reflexology
    • Holistic Nutrition
  • New Patients
    • How to Get Started
    • Adult New Patient Form
    • Child New Patient Form
  • Blog
  • Contact
  • Directions
  • (519) 966-7880

Adult and Adolescent New Patient Form

  • Step 1
    All new patients are requested to thoroughly complete a confidential “Health Record”.
  • Step 2
    Your first “Consultation” with the doctor is to discuss your health problems and goals.
  • Step 3
    You will receive a “Chiropractic Examination” to determine if chiropractic care is appropriate for your condition.
  • Step 4
    An in-depth, advanced assessment of your nerve and energy system will be completed to determine how well your brain is communicating with your body. Any interference to this communication may be measured by the following tests: Spinal Function, Range of Motion, Postural Assessment, Muscle Testing, Spinal Scans. As well, if indicated, x-rays will be taken to visualize the location of spinal problems.
  • Step 5
    You will be given an appointment to return for your “Report of Findings”, when your doctor will inform you as to your examination results and how we may help. The best course of action and a recommended treatment program will be explained to you.
  • Step 6
    Chiropractic care will begin after your Report of Findings and continue as scheduled until your condition has been fully corrected, or until the maximum possible improvement has been obtained.

To save time and allow us to better serve you, please complete all questions on the next pages. Thank you!

PERSONAL INFORMATION




REASON FOR CONSULTATION


Addressing What Brought You Into This Office:

Please list your health concerns according to their severity: Rate of severity
1 = mild
10 = worst
When did this episode start? If you had this condition before, when? Did the problem begin with an injury? % of the time pain is present
1.
2.
3.
4.





HEALTH HISTORY

Throughout your life, have you ever had any accidents, falls, traumas, sport injuries or work injuries? Please note all accidents, even if they seem minor to you.



Throughout your life, have you had any surgeries or hospitalizations?



Pregnancy: (Female section)



Family history:

HEALTH HABITS


Chiropractic is a global approach that takes into consideration all aspects of your health. The benefits of chiropractic are extended to all systems of the human body and an imbalance in your nervous system can manifest itself in many ways. It is therefore important for us to know your state of global health in order to offer you the best chiropractic experience.

SYSTEMS REVIEW

Do you suffer from difficulties with your…(please check all that apply)



Stressors: Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had or are currently experiencing) in each category:

1. Physical stress (falls, accidents, work postures, etc.)


2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)


3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)





What are your expectations and goals by coming here, how might we be able to help you? Indicate your top 3 goals.


Why Chiropractic Care?

People go to a Chiropractor for a variety of reasons. Some go for symptomatic relief of a condition (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Still others want whatever is malfunctioning in their bodies brought to the highest state of health possible with chiropractic care (Preventative Care). These are the three phases of care. Your doctor will weigh your needs and desires when recommending your schedule of care. How long you choose to benefit from Chiropractic is always up to you.




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