ADULT INTAKE FORM | ForeverYoung Chiro

Adult Intake Form

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

How did you hear about us?

Patient First Name

Patient Last Name

Birth Date

Phone

Street Address

City

Postal / Zip code

Region/State/Province

Name of Spouse/Partner

Name of Children + Ages

Occupation

Employer

Band Member ID (where applicable)

HEALTH CARE PROVIDERS

Family Doctor

Midwife

Doula

OB/GYN

Naturopath

Massage Therapist

Acupuncturist

Other Care Providers

Please any health conditions you have been treated for in the last year

PATIENT SYMPTOMS

Describe your chief complaint

When did it start?

What may have caused it?

What makes your complaint feel worse?

If yes, what time?

If yes, how?

If yes, when?

If yes, when was your last day of work?

If yes, how?

What makes your complaint feel better?

How does your complaint interfere with the following areas of your life?

Family:

Work/School:

Sports/Hobbies:

MEDICAL HISTORY

Date of last accident?

If yes, how many accidents?

Known trauma from accident?

If yes, what?

Please list all -

If yes, what?

If yes, what do you smoke and how much per week?

If yes, how much per week?

If yes, how many drinks per week?

WOMEN'S HEALTH

If yes, how many weeks?

If yes, how many?

If yes, what?

Average length of cycle?

If yes, what?

QUALITY OF LIFE

Is there any other information you would like us to know?

What do you expect from your chiropractic care?

FAMILY CONCERNS

Does your spouse/partner have any health concerns?

Do any of your children have any health concerns?

Thanks for submitting!

HEALTH CARE PROVIDERS

PATIENT SYMPTOMS

MEDICAL HISTORY

WOMEN'S HEALTH

QUALITY OF LIFE

FAMILY CONCERNS

613-507-5007

613-966-5855