New Patient Form- Adult

Name
Gender
Birthdate
Address
Consent for periodic emails regarding office updates or holiday hours/closures for example
Have you been to a chiropractor before?
Main goal in consulting our office:
Did your complaint(s) arise from a motor vehicle accident(MPI)?
MM slash DD slash YYYY
Is this realted to a Worker's Compensation claim(WCB)?
MM slash DD slash YYYY
Body Diagram- Please use the fields below to enter and describe each area of concern

Region 1

Region 2

Region 3

Region 4

How long have you been living this way?
Did your main complaint(s) come on:
Is/are the complaint(s) getting:
Is the complaint:
This discomfort interferes with my:
Have you had any of the following in the last year?
Have you ever had or to you presently have any of the following?
.
.
Blood pressure(if known)
Past motor vehicle accident(s)?
Any notable accidents or falls where injury occurred?
Any significant sports injuries?
Smoke?
How many alcoholic drinks per week?
Exercise regularly?
Healthy weight?
Poor posture?
More than 5 hours at a computer per day?
Sleeping posture:
Repetivie strain?
Mental stress?
Consent for Communication/Release of Information: I hereby authorize/grant permission to Thrive Chiropractic to communicate with other healthcare professionals, insurance providers, MPI(if applicable), and/or the Worker's Compensation Board (if applicable), with respect to my file or claim.
Consent for Examination and/or X-ray Study: I hereby consent to a chiropractic examination and x-ray evaluation(if necessary) to determine the most appropriate treatment plan. FOR FEMALES- I also certify that to the best of my knowledge, I am not pregnant. I understand that x-ray may cause harm to an unborn child.
This field is for validation purposes and should be left unchanged.