ADULT INTAKE FORM | ForeverYoung Chiro

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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!

Who may we THANK for Referring you?

Patient First Name

Patient Last Name

Gender

Phone

Birth Date

Email

Street Address

City

Postal / Zip code

Region/State/Province

Country

Name of Spouse/Partner

Name of Children + Ages

Occupation

Employer

Band Member ID (where applicable)

HEALTH CARE PROVIDERS

Massage Therapist

Acupuncturist

Doula

Family Doctor

Counselor

Naturopath

Athletic Therapist

Midwife

OB/GYN

Other Care Providers

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

Have you had previous chiropractic care; if so, where?

If yes, have you been adjusted?

Reason for Visit: (please check one)

PATIENT SYMPTOMS

Describe your chief complaint:

When did it start?

What may have caused the problem?

Complaint is getting:

Complaint started:

Duration of symptoms:

Has this hapened before; if so when?

What makes your complaint feel worse?

What makes your complaint feel better?

Is the complaint worse at a certain time of day; if so when?

Does the weather affect your complaint; if so how?

How does your complaint impact your Quality of Life in the following areas?

Family:

Work / School:

Sports / Hobbies:

Sleep

Appetite

Physical History & Stress / Trauma

Have you been involved in an Auto/ATV accident?

Any known trauma from accident?

Have you been involved in any sports / recreational traumas?

If yes, what?

Any hospitalizations or surgeries?

If yes, what?

Postural Stress / Habits?

Sitting > 6hrs.

Standing > 6hrs.

Computer > 6hrs.

Repetitive Lifting > 15lbs.

Current Level Of Exercise?

None

30min. Daily

1-2x Week

3-5x Week

Type of exercise?

Yoga

Strength

Pilates

Cardio

Other

Chemical & Environmental Stress / Toxins

Are you on any type of medication? (please list all and what for)

Do you take any supplements? (please list all and what for)

Do you experience frequent illnesses / colds / flus / respiratory?

Do you have any environmental allergies; if yes, please explain?

Do you have any food allergies; if yes, please explain?

If you smoke; what do you smoke and how much per week?

How much soda pop do you drink a week?

How much alcohol do you consume a week?

How many times do you eat fast food a week?

Rate your Current nutritional intake?

Poor

Fair

Good

Excellent

How many cups of water do you drink in a day?

No water

1-4 glasses

5-8 glasses

8+ glasses

Emotional Stress / Trauma

Current level of negaive stress?

None

A Little

Moderate

Too Much

How do you cope with negative stress?

Poorly

Fair

Well

What is currently causing you the most negative stress?

Rate yor current energy level:

Exhausted

Low

Good

Excellent

What is your ideal sleep position?

Stomach

Back

Side

All Over

How much sleep do you get per night?

< 3 hrs

4 - 5 hrs

6 - 7 hrs

8 + hrs

Family history of?

Heart Disease

Diabetes

Arthritis

Cancer

Other

Women's Health History / Trauma

Have you had any previous pregnancies and births?

Are you currently breastfeeding or pumping for bottle feeding?

Are you currently trying to conceive?

Are you currently using birth control; if so, what?

Average length of menstrual cycle?

Do you have painful periods?

Any pelvic conditions (PCOS, endometriosis, fibroids, hysterectomy)?

Are you currently undergoing Hormone Replacement Therapy?

Chiropractic Goals

What do you expect from your chiropractic care?

Relief Care Only

Correction & Prevention

Lifestyle Wellness Care

What is your greatest motivation for care in our office?

Time with Family

Ability to Work

Participation in Sports / Hobbies

Better Mobility

Pain / Symptom Relief

Overall Health

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

Family Concerns

Does your spouse / partner have any health concerns?

Do any of your children have any health concerns?

Thanks for submitting! We have received it.

613-507-5007

510 Canatara Court

Kingston, ON K7M 0G3

613-966-5855

Shannonville, ON K0K 3A0

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