Adult and Adolescent New Patient Form - The Holistic Wellness Centre

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

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.

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

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:

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.

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.

Please check the type of care desired so that we may be guided by your wishes whenever possible:
Preventative Care – Life Enhancement and Wellness CareCorrective Care – Removing Cause and Remodeling Soft TissueRelief Care – Symptom Care OnlyCheck here if you want the doctor to select the type of care appropriate for your condition

Authorization*:
I recognize that the given information is exact to the best of my knowledge and I consent to receive any necessary examinations. I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment.

	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
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