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Oaktree New Patient Chiropractic Forms
Patient Information
Patient Name
*
First Name
*
Last Name
*
Address
*
Address Line 1
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Date of Birth
*
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Month
Jan
Feb
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Apr
May
Jun
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Year
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2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
Weight:
Height:
Email Address
*
Cell Phone
*
Home Phone
Work Phone
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Common-law
Workplace / Occupation:
Medical Doctor Name:
Do you have kids?
Yes
No
Referral:
*
How did you hear about Oaktree Health?
I consent to receiving email communication from Oaktree
*
Yes
No
(Emails we will send you include news updates from Oaktree. We will not spam you and you can unsubscribe at anytime. You will still receive appointment reminders and other important notices via email)
Chiropractic History
Have you been to a Chiropractor before?
*
Yes
No
Were x-rays taken?
Yes
No
Name of Chiropractor and City
Approximate date of last visit:
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
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21
22
23
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26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Duration and Frequency of Care:
Primary Health Concern
What is your present primary health concern?
*
How long have you had this condition?
*
What aggravates your condition?
What relieves your condition?
Are you getting pain or numbness in your arms or legs? Explain:
Is your condition getting progressively worse?
*
Yes
No
It's constant
It comes and goes
Pains are:
Sharp
Dull
Burning
Tight
Pain severity (currently)
1
2
3
4
5
6
7
8
9
10
Pain severity (at it's worst)
1
2
3
4
5
6
7
8
9
10
Other health care professionals who treated this condition: What else have you tried?
What is this affecting that is MOST important in your life (list all the apply)
What health goal, if you were to complete it or accomplish it, would have the greatest impact on your life?
Secondary Health Concern (if applicable)
What is your secondary primary health concern?
How long have you had this condition?
What aggravates your condition?
What relieves your condition?
Are you getting pain or numbness in your arms or legs? Explain:
Is your condition getting progressively worse?
Yes
No
It's constant
It comes and goes
Pains are:
Sharp
Dull
Burning
Tight
Pain severity (currently)
None
1
2
3
4
5
6
7
8
9
10
Pain severity (at it's worst)
None
1
2
3
4
5
6
7
8
9
10
Other health care professionals who treated this condition: What else have you tried?
What is this affecting that is MOST important in your life (list all the apply)
What health goal, if you were to complete it or accomplish it, would have the greatest impact on your life?
Conditions and Symptoms
Head/Neck
None
Blurred / failing vision
Deafness / ringing in ears
Earaches
Sore throat / tonsillitis
Thyroid problems
Sinus problems
Environmental allergies
Thyroid Disease
Other:
Other Value
Check any past/current patient problems
Cardiovascular System
None
Chest pain
Shortness of breath
Heart medication
High blood pressure medication
High cholesterol medication
Swelling of legs
Other:
Other Value
Check any past/current patient problems
Respiratory System
None
Frequent bronchitis
History of pneumonia
Chronic cough
Spitting up phlegm / blood
Difficulty breathing
Tuberculosis
Pneumonia
Asthma
Other:
Other Value
Check any past/current patient problems
Digestive system
None
Heartburn / indigestion
Stomach cramps
Constipation / diarrhea
Food allergy
Food intolerances
Other:
Other Value
Check any past/current patient problems
Musculoskeletal system
None
Painful joints
Painful muscles
Tendinitis
Bursitis
Arthritis
Headaches / migraine
Neck pain / stiffness
Tension across shoulders
Numbness - tingling: arms / hands
Numbness - tingling: legs / feet
Mid - back pain / stiffness
Lower - back pain / stiffness
Scoliosis / spinal curvatures
Faulty posture
Painful tailbone
Foot trouble
Other:
Other Value
Check any past/current patient problems
General symptoms
None
Fever / chills / sweats
Frequent colds
Fainting / dizziness
Seizures / convulsions
Skin problems
Tremors
Loss of balance
Unexpected weight loss / gain
Anemia
Alcoholism
HIV / AIDS
Loss of sleep
Poor memory / concentration
Learning disability
Irritable / nervous / tension
Depression / emotional problems
Anxiety
Decreased energy / fatigue
Tired / lethargic
Autoimmune disease
Antibiotic ude
Cancer
Other:
Other Value
Check any past/current patient problems
Females only
None
Painful mensuration
Cramps or backaches
Peri - menopause
Passed menopause
Currently pregnant
Excessive / irregular flow
Abnormal discharge
Miscarriages
Other:
Other Value
Check any past/current patient problems
Previous Traumas
Motorized Vehicle Accidents: Year and description
Motorized Vehicle Accidents (2): Year and description
Falls and Injuries (Regardless of age)
From heights, down stairs, other falls, broken bones, childhood falls, other injuries, etc.
Posture and Habits
None
Sitting > 6 hours/day
Stomach sleeper
Head forward posture
Computer/phone > 3 hours a day
Activities that are repetitive in nature
Serving or catering
Crafting, etc.
Leaning or sitting on one hip
Cross legs often
Participation in high impact activities:
None
Hockey
Running
Wrestling
Basketball
Climbing
Football
Mountain Bike
Gymnastics
Occupational Stress - Ocupation
Occupational Stress - My job requires:
None
Heavy lifting
Awkward positions
Repetitive stresses
Sitting for long periods
Occupational Stress - Previous applicable occupation:
Occupational Stress - Work injuries:
Birth Trauma - How many births have you had?
Birth Trauma - Was your birth:
None
Difficult / long
Forceps
C-section
Epidural
Suction
Resuscitation
Other:
Other Value
Birth Trauma - Have you ever given birth? Was it:
None
Difficult / long
Forceps
C-section
Epidural
Suction
Resuscitation
Other:
Other Value
Overall Health:
*
1
2
3
4
5
6
7
8
9
10
1= Poor, 10 = Excellent
Commitment to Health
*
1
2
3
4
5
6
7
8
9
10
1= Not committed as all, 10 = Highly committed
Disease Causation Analysis
Exercise - How often do you stretch per week?
0 days a week
1-2 days a week
3-4 days a week
5-7 days a week
Exercise - How often do you participate in aerobic exercise?
0 days a week
1-2 days a week
3-4 days a week
5-7 days a week
Emotional Stress - Are you currently experiencing stress in the following areas?
None
Marriage
Kids
Finances
Work
Elderly parents - caregiver
Recent major life events (births, deaths..)
Family Health History - what significant health concerns have your family members experienced?
Parents and siblings
Equipment - Mattress age and type
Please specify type: coil, foam, rubber, etc.
Equipment - Pillow
Ergonomic neck support
Feather
Foam
Other:
Other Value
Equipment - Do you wear:
Custom orthotics
Over the counter foot orthotics
Foot lifts
Heel lifts
Over the counter foot supports
Chemical Stresses - Do you feel that you make healthy food choices?
Yes
No
Don't know
Other:
Other Value
Chemical Stresses - How would you describe your nutrition?
Chemical Stresses - Are you at your ideal body weight?
Yes
No
Don't know
Other:
Other Value
Chemical Stresses - Do you take any supplements? Which ones?
Example: Omega 3, Vitamin B, Probiotics, Vitamin D, Multivitamin, Iron
Chemical Stresses - Do you presently:
Smoke
Use recreational drugs
Have a history of addiction (please explain in "other")
Chemical Stresses - Do you consume alcohol? If so how often:
No
1-3 days/week
Daily
More than 1x our day
Other:
Other Value
Medical History Health Conditions
Please list current diagnoses:
Medications - Name and for which condition(s)
Surgeries - For what conditions(s) (Include year preformed)
Please list any other details that may assist the Doctor in understanding your lifestyle and health status:
I understand that the purpose of today's visit is to determine if I am a candidate for chiropractic care and that I am responsible for any fees agreed upon by myself and the attending doctor. All examination fees will be explained to me before any tests are performed (Patients may be requested to sign a presented hard copy of this document upon arrival)
*
Date
*
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Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
Signature
[clear]
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