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+519 719 7913
677 Richmond St London, Ontario
Home
About
Our Philosphy
Benefits of NSA
Services
Network Chiropractic Care
HypnoBirthing
Resources
What to Expect & Forms
Contact
Book Now
Health Profile Form
Dr Jenna | Network Care Practitioner
Name:
*
Address:
*
City
*
Province:
*
Postal Code:
*
Date of Birth:
*
MM slash DD slash YYYY
Home Phone:
Work Phone:
Cell Phone:
Height:
Weight:
Marital Status:
Single
Married
Widowed
Divorced
Spouse Name (If Applicable):
Name
Number of Children:
Occupation:
Email
Who referred you to our office and the professional services we offer?
Have you had any Chiropractic Care in the past?
Yes
No
If yes, were you pleased with their care?
Yes
No
PLEASE ANSWER THE FOLLOWING QUESTIONS ABOUT YOUR PERSONAL HISTORY
1. Do you have any health concerns/ symptoms?
Yes
No
Please Describe:
2. How do these health concerns interfere with the following areas of your life? Work, Family, Hobbies, Life:
3. Have you done anything or sought treatment for this situation or concern?
Yes
No
If Yes, What were you told:
4. What was done? Did it seem to work?
5. What was different about YOU, after the treatment?
6. What was different about your CONDITION or SYMPTOM after your treatment?
7. Why do you think this has happened (or continues) to happen to you?
Do you think this is the sole cause?
Yes
No
If No, what else is involved?
8. If this condition or symptom were to go away tomorrow, what would be different about your life?
*On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem:
9. How do you feel about your current condition? (Please choose ONE that BEST describes how you feel)
I feel helpless; nothing works.
I don’t like what I’m feeling, and I hope you can fix it.
I feel this is a pattern that has happened to me before; it is back again.
I feel there is a message my body is giving me.
I am looking for something to help me enhance my quality of life and further enhance my wellness
10. What do you hope to receive from care in this office?
-- PHYSICAL HISTORY --
Birth Stress: Information about your birth history:
1. Did your mother have a difficult pregnancy with you?
Yes
No
2. Was your birth traumatic?
Yes
No
3. Was your birth:
Drug Induced
C-Section
Natural (No Drugs)
Forceps or Suction
Prolonged
Cord around neck
Breech
Other
GENERAL PHYSICAL TRAUMA
4. Were you ever knocked unconscious?
Yes
No
How/When?
5. Have you ever broken any bones?
Yes
No
How/When?
6. Have you ever had any impacts and/or falls that you feel specifically may have injured your spine?
Yes
No
How/When?
7. Have you ever injured your head, neck, back or hips?
Yes
No
How/When?
8. Have you served in the military?
Yes
No
If yes, were you involved in combat?
Yes
No
9. On average, how many hours per day do you participate in the following? Standing, Desk Work, Phone Work, Computer Work, Driving, Lifting Heavy Objects, Manual Labour, Stooping/Bending/Kneeling
SPORTS OR LEISURE
10. Were you, or are you active in any sport(s)?
Yes
No
Which One(s)?
11. Have you been hurt in any of these activities?
Yes
No
Where?
AUTOMOBILE ACCIDENTS
12. Have you, (even as a passenger, even if you do not think you were hurt), been involved in a car accident, or near collision?
Yes
No
Please list approximate dates and severity:
Bus, bicycle, motorcycle, train, airplane, moped, or other vehicles:
MEDICAL TREATMENT
13. Have you ever been hospitalized?
Yes
No
If yes, what was done to you?
14. Have you had surgery?
Yes
No
If yes, what was done to you?
15. Have you ever had:
First ChoiceSpinal Tap
Spinal Injections
Physiotherapy
Neck Collar
Spinal Brace
Heel Lift
X-Ray Treatments
Corrective Shoes or Bars
Traction
Extensive Diagnostic X-Rays
Acupuncture
Chemotherapy
Blood Transfusion
Body Part in a Cast or Immobilized
-- CHEMICAL HISTORY --
BIRTH STRESS:
1. Was your mother regularly taking any drug prior to, or during her pregnancy with you?
Yes
No
2. Did she use: Alcohol, Cigarettes, Other
3. Was her labour chemically induced or altered?
Yes
No
4. Was your mother:
Conscious
Semi-Conscious
Unconscious during delivery
Under spinal anesthesia during delivery
GENERAL CHEMICAL TRAUMA
5. Are you taking any drug(s) (prescription or over-the-counter) regularly? Please list drug(s), when prescribed and reasons for taking them:
6. Do you now, or in the past, have a history of alcohol/drug abuse or heavy use?
Yes
No
Please Describe:
7. Do you or did you work with any chemical, fume, dust, powder, smoke for prolonged periods?
Yes
No
Please Describe:
8. Please indicate how much of the following products you consume:
Alcohol – Drinks/week:
Coffee – Cups/day:
Coffee – Cups/day:
Tobacco – Amount/day:
Tobacco – Amount/day:
Artificial Sweeteners:
Artificial Sweeteners:
Soda - #/day:
Soda - #/day:
Refined Sugar – Candy/Pastries/day:
Refined Sugar – Candy/Pastries/day:
9. Do you use commercial household cleaners and personal care products (ie. Lysol, Tide, Dove, Mr. Clean, etc.)?
Yes
No
Have you experienced any symptoms related to their use? If YES, what?
Would you be interested in learning about healthier products to use for your home and body?
Yes
Not at the Time
- EMOTIONAL HISTORY –
1. HOW DO YOU GRADE YOUR MENTAL/EMOTIONAL HEALTH?
Excellent
Good
Fair
Getting Better
Getting Worse
2. Have you experienced any emotional/mental traumas or situations in your childhood? If so, please describe:
3. Have you experienced any recent emotional/mental traumas? If so, please describe:
- OVERALL STRESS SURVEY -
Please grade your Past/Current Life Stresses using the following scale:
0 – No awareness of any stress
1 – Slight stress
2 – Moderate stress
3 – Extreme stress
A) Overall Physical Stress/Trauma: (includes: falls, accidents, injuries, repeated postural stress, impacts, difficult birth, physical abuse, loss of consciousness, broken/fractured bones, etc.)
0
1
2
3
B) Overall Emotional/Mental Stress: (includes: loss of loved ones, rapid change in life situations, abuse, move of home/school, legal concerns, financial concerns, divorce, relationships, etc.)
0
1
2
3
C) Overall Chemical Stress: (includes prescription drugs, over-the-counter medications, smoking, alcohol, caffeine, fumes, food additives, anesthesia, etc.)
0
1
2
3
YOUR SPECIFIC NEEDS AND HOPES FOR HELP IN THIS OFFICE?
Your Specific Needs and Hopes for Help in this Office
Very Important to Me
Important to Me
Not so Important to Me
Does Not Apply
1. In published study of health and wellness benefits for patients under Network Care, conducted at the University of California, Irvine Medical College, patients reported an overall improvement in all of the following categories of health and wellness listed below (highlighted in BOLD). How do you hope to benefit from care in this office? (use scale from above to answer each category)
Improvement of my Physical Symptoms
0
1
2
3
Improvement of Emotional/Mental Symptoms
Improvement of Emotional/Mental Symptoms
0
1
2
3
Improvement in Enjoyment of Life and the ability to make Healthier, more Constructive Choices
Improvement in Enjoyment of Life and the ability to make Healthier, more Constructive Choices
0
1
2
3
Improvement of my Ability to React or Respond to Stress
Improvement of my Ability to React or Respond to Stress
0
1
2
3
Overall improvement in Quality of Life
Overall improvement in Quality of Life
0
1
2
3
2. Is there anything else you may wish to share which may help us better understand you, your history, or your professional and personal needs which have not been discussed in this profile? (if necessary, please use the back of this form)
3. What would motivate you to tell others about the care you receive in this office and encourage others to get under Care?
Phone
This field is for validation purposes and should be left unchanged.
Dedicated Support Team
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