Intake Form

Personal Information

First Name

Middle Initial

Last Name

Date of Birth

Gender

You are:

E-mail

This gives you access to online booking and to receive e-mail reminders for your upcoming appointments.

Primary Language

Preferred Document Language

Contact Information

Address 1

Address 2

City

Province

Postal Code

Phone Number (Home)

Phone Number (Work)

Phone Number (Cell)

Emergency Contact

Name

Phone Number

Visit Information

Referred By

Family Physician

Medicare Number

Main Complaint / Reason For Visit

Please provide as many details as possible (eg. Neck pain, tingling in fingers, etc.)

Please list any medication that you are currently taking

Have you had any surgeries in the past 5 years?
YesNo

If so, please specify:

Have you had any hospitalizations in the past 5 years?
YesNo

If so, please specify:

Have you ever been diagnosed with cancer?
YesNo

If so, please specify:

For Female Only

This is to certify that, to the best of my knowledge, I am not pregnant. The Doctor of Chiropractic has my permission to take x-rays. I will assume all responsibility for all effect on a fetus potentially present.