Welcome to the Café of Life
When
you have completed this page please hand it into the reception desk.
Date:_________,06
Name___________________________________Middle Initial:___
How do you wish to be addressed in our office?
¨First name ¨Mr.
¨Mrs.¨Ms.
¨Miss
¨Dr.
Date of Birth: D___ M ___ Y _______ Age _______
Address_________________________________________ City ______________ Province____
Postal Code______________
Marital Status: S
M D
W Spouse’s Name
_______________________________
Number of children ____
Home Phone ___________________ Best time to reach you at home?_________
Cell Phone __________________ E-mail _________________________
Business Phone __________________ Ext._____
Business/Employer__________________________
Type of work___________________________
Best time to reach you at work? ___________
Whom can we thank for referring you to the Café of Life ?______________________________
Have you ever been adjusted by a chiropractor? ¨ Yes ¨ No
Have you ever experienced Network Spinal Analysis? ¨ Yes ¨ No
To develop an understanding about Network Spinal Analysis, your body’s
healing ability, life force and the nervous system we request that you attend
one of our special health seminars during your first month of care.
Are you interested in attending one of our seminars?
¨
Yes ¨
No
Part I: Your Health Concerns and the Impact on your Life
1.Do you have any current health concerns? If so, please describe ______________________________
_____________________________________________________________________________________
2. When did this/these health concern(s)
begin?_______________________________________________
____________________________________________________________________________________
3. Have you done anything about this situation or concern or gotten any
advice or treatment for it?
If yes, what were you told?
____________________________________________________________
4. What was done?_______________________________________ Did it seem to
work?_____________
5. If you did not have this condition/symptom, what would be different
in your life?
____________________________________________________________________________
6. Why do you think you are experiencing this health concern?
__________________________________________________________________________________
7. If this condition or symptom were to go away tomorrow, what would be
different about your life?
____________________________________________________________________________________________________
8. Please grade the level to which this (these) health concern(s) effect these aspects of your functioning/quality of life.
0- It does not seem to affect me.
1- It seems to slightly affect me.
2-
It seems to moderately affect me
3- It seems to drastically affect me.
Affect on work 0 1
2 3
Affect on recreation/play 0
1
2 3
Affect on rest/sleep 0
1 2
3
Affect on social life
0 1 2
3
Affect on walking 0
1 2
3 Affect on sitting
0 1
2 3
Affect on exercise 0
1 2
3
Affect on eating 0 1
2 3
Affect on love life 0
1 2
3
Concern about health
0 1 2
3
The overall impact of my symptom(s)/condition(s)
on my life is
0 1
2 3
How aware are you of your health concerns
during day? 0 1 2
3 At
night? 0
1 2
3
9. Which best describes your current feeling about yourself and you
situation?
a)
I feel helpless, it seems little or nothing works.
b)
This feels terrible; I am scared, and hope you can fix it for me.
c)
I feel stuck, and can’t help myself right now.
d) I deserve more than what I have been experiencing with my body, and would like you to
assist me in my healing.
e)
Anything
else?________________________________________________________________
10. Please grade the following on a scale of 0 to 3,
0- not at all
1- slight 2- moderate 3-extreme,
a)
Currently, how inconvenient is your situation, condition or symptom? 0
1 2 3
b) How inconvenient was it in the past? 0 1 2 3
Part
II: Your Specific needs and Hopes For help in This Office?
11.What do you hope to receive from chiropractic care at the Café of Life?
______________________________________________________________________
Use
this scale for question 12: a)
very important to me
b) important to me
c) not so important to me
d) does not apply
12. How do you hope to
benefit from care in the office?
i)___Improvement of my physical symptoms
ii)___Improvement of emotional/mental symptoms
iii)___Improvement of my ability to react or respond to stress
iv)___Improvement in enjoyment of life and the ability to make
constructive choices
v)___Overall improved quality of life
13. Did you know that all of the above is available to you and your family by receiving care at the
Café of Life?
¨
Yes ¨
No
14. Is there anyone in your
life that could also benefit from receiving care at the Cafe of Life?
___________________________________________________________________________________
Name:_____________________________________
Date:_________________
Network Spinal Analysis will cause your body to create new strategies that will connect and release
to tension that has built up in your system and has suppressed your life flow. Tension in your system
can originate from how you perceive you environment, physical demands on the body and what you
consume.
PHYSICAL HABITS AND EVENTS
EFFECTING YOUR LIFE FLOW
¨ “C” section ¨ cord around the neck
¨ breech ¨ prolonged
16. Have you ever had any impacts, falls, or jolts that you feel specifically may have injured your spine?
When and
How?:______________________________________________________________________
17.
Have you ever broken any bones? ¨
Yes ¨
No Where?:__________________________________
18.
Do you have problems opening or closing your jaw?
¨
Yes ¨
No
19.
Do you clench your jaw or grind your jaw at night?
¨
Yes ¨
No
20.
During the day I (indicate approx. time):
¨
Sit, ___hrs ¨ Stand, ___hrs ¨
Walk, ___hrs
¨
Work on computer, ___hrs
¨
Phone work, ___hrs
¨
Drive, ___hrs
¨
Do repetitive work, ___hrs ¨
Heavy Lifting, ___hrs
21.
I am presently exercising: ¨
1x a Week ¨ 3x a Week ¨
5x a Week ¨ Daily
Describe
type, duration and intensity for each
activity/sport:_________________________________
_____________________________________________________________________________
22.
I stretch: ¨
yes, ¨
no. If yes, how often?_____________
23.
Do you play a musical instrument?
¨
Yes ¨
No Instrument(s):____________________
24.
How many hours a week do you watch television? ____hrs.
Automobile accidents:
25. Have you, (even as a passenger, even if you do not think you were
hurt), been involved in a
motor vehicle collision, or near collision. Please list approximate dates and severity (Mild, Moderate or
Extreme):________________________________________________________________________
__________________________________________________________________________________
Medical Treatment:
26. Have you ever been hospitalized?
¨
Yes ¨ No If yes, what was
actually done to you?______
___________________________________________________________________________________
27. Have you had surgery? ¨ Yes ¨
No If yes, when and what was
done_______________________
28. Have you had:
¨
a spinal tap ¨ spinal injections
¨
physiotherapy ¨
neck collar
¨
spinal brace ¨
traction ¨ heel lift ¨
corrective shoes or bars on shoes
¨
extensive diagnostic x-rays
¨
acupuncture ¨ chemotherapy
¨
transfusion
¨
body part in a cast or immobilized.
29. How do you grade your physical health? - ¨
Excellent ¨ Good ¨
Fair ¨ Poor
- ¨
Getting better
¨
Getting worse
30. Was your mother regularly taking any drug immediately prior to, or
during her pregnancy with you?
¨
Alcohol ¨
Smoking
¨
Medications ¨
Coffee
¨
Recreational drugs
Other?:____________________________________________________________________________
31. Was her labour chemically induced or altered?
¨ Yes
¨
No
32.
Are you taking any drug (prescription or over-the-counter) regularly?
Please list drugs, when
prescribed
and reasons for taking them:___________________________________________________
__________________________________________________________________________________
33. Are these drugs being prescribed by a physician?
¨ Yes ¨
No Last Visit Date:____________
34. In the past, have you taken other medications for a period of more
than 3 months? ¨
Yes ¨ No
a) What did you
take?___________________________________________________________
b) What was the
reason for taking this medication?____________________________________
35. Do you or did you work with any chemical, fume, dust, powder or
smoke for prolonged periods?
¨
Yes ¨ No Describe
where and how often:____________________________________________
36. In the first column write the number of average daily consumptions of each product. In the second
column write the number of average weekly consumptions or each
product.
___ ___Alcohol (beer, wine,
liquor)
___ ___Vitamins, # of vitamins_____
___ ___Beef
___ ___Coffee or Tea, (reg ¨
decaf ¨) ___
___Cooked, canned vegetables ___ ___Chicken
___ ___Tobacco (cigarettes)
___ ___Raw vegetables ___ ___Fish/Seafood
___ ___Artificial
Sweeteners
___ ___Cheese, yogurt, ice cream ___ ___Eggs
___ ___Soft drinks, Diet ¨
___ ___Bread, Type__________
___ ___Fried Foods
___ ___Recreational drugs
___ ___Medications, # of pills _____
___ ___Milk
___ ___Sweets / Candy ___ ___Fast foods
___ ___Fruit
___ ___Water
37. Based on my daily and weekly consumption found above I feel the
intake into my body is?
¨ Excellent (I have little to improve on and I am consistent in my eating habits) ¨ Good (I know of a couple
areas I can improve) ¨ Poor (there are a few things I am consuming that are effecting my health
¨
Very Poor (the intake into my body must be causing major chemical stress to it)
Lately, my diet has been ¨
Getting better
¨
Getting worse
38. Was your mother under major stress or did she have any life changing events during her pregnancy
with you? ¨
Yes ¨
No
39. Circle “P”
for past stress or “C” for current stress, if it applies to you.
Mild
Moderate Extreme
Mild Moderate
Extreme
Childhood stress
P C
P C P
C
Work related stress P C
P C
P C
School stress P C
P C P
C
Stress of commuting P C
P C
P C
Play, or recreational P C
P C P
C
Loss of a loved one
P C
P C
P C
Family stress P C
P C P
C
Change in lifestyle
P C
P C
P C
Personal relationships P C
P C P
C
Change in vocation P C
P C
P C
Stress of being sick P C
P C P
C
Stress from abuse P C
P C P
C
40. Do you feel stressed out? ¨ Yes ¨
No
41. I sleep _______ hours a night?
42. Do you feel rested when you wake up? ¨
Yes ¨ No
43. Do you have trouble falling asleep or do you wake up frequently at
night? ¨
Yes ¨ No
44. Do you have trouble relaxing? ¨
Yes ¨ No
45. Do you feel like you have control of your life? ¨
Yes ¨ No
46. Do you feel like you have balance in your life? ¨
Yes ¨
No
47. Has any of your family members have any of the following health
conditions?
¨
Heart Disease ¨ Diabetes, type____________ ¨ Cancer, type_________________
¨ Depression ¨ Stroke ¨ Arthritis, type_____________. ¨ Hypertension
48. How do you grade your emotional/mental health?
¨ Excellent ¨
Good ¨ Fair ¨
Poor
¨
Getting better
¨
Getting worse
49. I am committed to improving my: Physical Health ¨,
Chemical Health ¨,
Emotional Health ¨