First
Name _____________________________ Last
Name _____________________________________
Address _______________________________________________________________________
City
___________________________ Province_____________
Postal Code________________________
Email
address _____________________________Website _________________________________
Home
Phone___________ Business Phone____________
ext _______ Mobile Phone _________________
Who
is your current employer? __________________ Occupation?
__________________________
Health
Card No. ____________________________________
Version Code ___________________
Date
of Birth: D____ /M ______
/Y __________
Marital
Status: ?
Married ?
Common Law ?
Single ?
Widowed ?
Divorced
Name of Spouse (if applicable): ______________________________________________________
Do you have children? ?
No ?
Yes - Names (ages): ____________________________________
Do your children live at home? ?
No ?
Yes, who? _____________________________________
Have
you or your family seen a chiropractor before?
? No ?
Yes | If so, when? _____________
Reason for seeking services at Café of Life:___________________________________________________
How did you find out about Café of Life? _______________________________________________
Is there anything about your nerve system and spine we should know
about? _____________________
______________________________________________________________________________
What
is your level of commitment to yourself, your life and well-being?
?
High
?
Medium
?
Low
Additional Comments: _____________________________________________________________
______________________________________________________________________________
Thank
you for completing this more detailed questionnaire.
All the information we collect is confidential and is valuable in order
for us to provide you with exceptional service. If you have any questions please ask the host or the
Chiropractor. Please inform the
host or the Chiropractor when you have completed this information.
First
Name ________________________ Last
Name ________________________________
Name
of previous chiropractor and date of last visit? _____________________________
Describe
Experience _____________________________________________________
Name
of present MD and address? ___________________________________________
_____________________________________________________________________
Date
and reason for last MD visit? ___________________________________________
Do
you have any current health concerns (i.e. pain, symptoms, disease)?
If yes, please describe and complete the following questions, if no
proceed to*_____________________________________
__________________________________________________________________________When
did this/these health concern(s) begin? __________________________________________
Have
you sought advice or treatment from a health professional?
?
Yes ?
No
If
yes, what were you told? ________________________________________________
What
was done?___________________________ Did
it seem to work? ?
Yes ?
No
Please
indicate how this condition affects your daily functioning and quality of life?
_____________________________________________________________________
What
concerns you about your situation? ______________________________________
_____________________________________________________________________
Why
do you think you are experiencing this health event? _________________________
_____________________________________________________________________
If
this condition or symptom were to go away tomorrow, what would be different
about your life?
*What
are your expectations of your chiropractic care at the Café of Life?_____________
_____________________________________________________________________
To
develop an understanding about Chiropractic, your body's healing ability, life
force and the nervous system we request that you attend one of our special
Wellness Lectures during your first month of care. Are you willing to attend one of our seminars?
?Yes ? No ? Will consider
Family
and Personal History:
Please
list whether you or anyone in your close family has a history of any of the following:
Cancer
_______________________________________________________________
Diabetes
______________________________________________________________
Heart
Disease/High Blood pressure __________________________________________
High
Cholesterol _______________________________________________________
Any
Other Health Concerns ________________________________________________
PHYSICAL
STRESSORS activities, habits, traumas or challenges:
Please
list the details and age/date (as necessary) of past and present PHYSICAL
experiences:
Your
birth: ?
Home ?
hospital ?
forceps ?
C-section ?
Other__________________
Surgeries/Hospitalizations
________________________________________________
Falls/Broken
Bones/General Trauma _________________________________________
_____________________________________________________________________
Car
Accidents (describe)__________________________________________________
Other
Past or Current Illness/Infection _______________________________________
List
any repetitive movements, low-level stresses, or prolonged postures you have
experienced over any extended period of time (ie work, driving, lifting,
exercise) ________________________
_____________________________________________________________________
How
many hours do you sleep a night? ____Quality? _______Sleeping Position?________
How
much (and what kind of) exercise do you get?_______________________________
_____________________________________________________________________
How
many hours per week do you watch television? ______________________________
Other
________________________________________________________________
CHEMICAL
STRESSORS activities, habits, traumas or challenges:
Please
indicate present and past exposures to (per day/week):
Cigarette
Smoke (current or past) ___________________________________________
Alcohol
______________________________________________________________
Refined
Sugar __________________________________________________________
Artificial
Sweeteners:____________________________________________________
Caffeine
______________________________________________________________
Environmental/Occupational
_______________________________________________
Past
Medications & Reason _______________________________________________
Current
Medications & Reason: ____________________________________________
Supplements:
__________________________________________________________
Allergies:_____________________________________________________________
Vaccinations:___________________________________________________________
Other:________________________________________________________________
What
are your typical daily food choices:
Breakfast:
_____________________________________________________________
Lunch:
_______________________________________________________________
Dinner:
_______________________________________________________________
Snacks:
_______________________________________________________________
What
is your daily fluid intake? How
many glasses of:
Water
__________ Juice _________ Pop______ Coffee/Tea ______________ Dairy___________
Other_________________________________________
EMOTIONAL/MENTAL
STRESSORS activities, habits, traumas or challenges:
Please
list details of past or present stress in the following areas:
Mother's
pregnancy with you ______________________________________________
Birth_________________________________________________________________
School
_______________________________________________________________
Work_________________________________________________________________
Financial______________________________________________________________
Relationships___________________________________________________________
Family________________________________________________________________
Illness________________________________________________________________
Abuse________________________________________________________________
Personality
(ie hold emotions in, quick tempered, perfectionist, etc):_________________
_____________________________________________________________________
Other
stresses __________________________________________________________
What
is your level of satisfaction with your career?
?
Great ?
OK ?
Dissatisfied
When
was your last vacation (describe)?_______________________________________
What
is the quality of your sexual relationship?
?
Great ?
OK ?
Dissatisfied ?
N/A
What
do you do for play and relaxation?_______________________________________
Do
you feel like you have control in your life?
?
Yes ?
Undecided ?
No
Do
you feel like you have balance in your life?
?
Yes ?
Undecided ?
No
Which
best describes your current feeling about yourself and you situation?
?
I feel helpless, it seems little or nothing works.
?
This feels terrible; I am scared, and hope you can fix it for me.
?
I feel stuck, and can't help myself right now.
?
I deserve more than what I have been experiencing with my body, and would
like you to assist me in my healing.
?
Anything else? ____________________________________________________
WELLNESS
Perception and Habits:
Have
you or do you use any of the following for your growth, healing and development?
?
Breathing exercises
?
Meditation
?
Prayer
?
Yoga/Thai Chi/Movement
?
Massage / body work
?
Acupuncture
?
Ayurvedic medicine
?
Physiotherapy
?
Homeopathy
?
Osteopathy/cranial work
?
Energy work
?
Psychotherapy
?
Other______________________________________________________________
How
would rate your physical health?
?
Great ?
OK ?
Fair ?
Poor
How
would rate your mental/emotional health?
?
Great ?
OK ?
Fair ?
Poor
How
would rate your spiritual health?
?
Great ?
OK ?
Fair ?
Poor
If
you consider yourself ill, why do you feel you are ill?___________________________
_____________________________________________________________________
If
you consider yourself well, why do you feel you are well?________________________