Downtown Pregnancy Chiropractic Forms

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Oaktree New Patient Pregnancy Chiropractic Forms

Patient Information

Patient Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

Province

Postal Code

Date of Birth*

Weight (current):

Height:

Email Address*

Cell Phone*

Home Phone

Work Phone

Marital Status*

Single Married Divorced Widowed Separated Common-law

Do you have kids? (If yes, how many and at what ages?)

Medical Doctor Name:

Workplace / Occupation:

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:

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?

Is your condition getting progressively worse?*

Yes No It's constant It comes and goes

Other health care professionals who treated this condition: What else have you tried?

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?

Is your condition getting progressively worse?

Yes No It's constant It comes and goes

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*

Signature

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Oaktree New Patient Pregnancy Chiropractic Forms

Patient Information

Chiropractic History

Pregnancy Related Questions

Primary Health Concern

Secondary Health Concern (if applicable)

Conditions and Symptoms

Previous Traumas

Disease Causation Analysis

Medical History Health Conditions