Form for the new Tall Ones
 Date:      
Before you begin, we would like to know to whom we owe an immense THANK YOU! for having referred you to us: 
Please fill out all questions to the best of your knowledge. Everything will be reviewed with you later.

Thank you!
Personal information
 
Last name:
First name:
Address:
Town/municipality/village:
Postal Code:
Phone Home:
Work:
Cell:
Is it ok to leave a message at these numbers?
Email:
Can we send emails to this address including a monthly private newsletter?   Yes No
Date of birth:
 (Day/Month/Year)
What is your occupation?
Where do you work?
Are you? Single Married With a partner Divorced Widowed
What is the name of your life partner?
What are the names of your children and their ages?
 
Present history
 
Please tell us your story in your own words. If you are consulting us for wellness, tell us what else you are doing to improve this state. If you are consulting for a particular issue, tell us how you think this started, what has happened to you and what you have done since.
Have you consulted another specialist for the same reason that brings you here?
Yes No
Have you ever received chiropractic care before? Yes No
 
Secondary objectives
 
Are there any other reasons for seeking care that you would like to have addressed eventually?
 
Life history
 As best as you know, how did your pregnancy go (when your mother was pregnant with you) and your birth?
Have you been a victim of birth trauma like
  Induction (provoked)  Diabetes  
  Peridural/epidural   Forceps/ventouse  Other, specify
Have you received routine vaccinations? Yes No
Date of most recent vaccine:
Have you suffered from adverse reactions following vaccination? Yes No
How was your health in general when you were...
 - A child? 
 - A teenager? 
Were you very involved in sports? 
 - Which sports in particular? 
If you are a woman, how was the beginning of your periods? 
 - An adult? 
Date of most recent bloodwork:
Do you suffer from imbalances like:
 Elevated cholesterol  Diabetes  
 Hypertension  Anemia  Other chronic problem, specify
Have you ever…
Had surgery? Yes No If yes, when and why?
Been a victim of falls, car collisions or other trauma? Yes No
Broken any bones or lost consciousness? Yes No
Been hospitalized? Yes No
 
Family history
 
Are your father and mother in good health? Yes No
If no, specify briefly: 
Is there a history of heart or thyroid conditions or particular cancers in the family? 
If you have brothers, sisters and/or children, are they healthy? Yes No
 
Lifestyle
 
Do you take any medications (drugs), including the birth-control “pill”? Yes No
Do you take supplements, including vitamins? Yes No
Do you take any coffee, tea and/or soft drinks? Yes No
Do you smoke cigarettes, marijuana and/or haschich? Yes No
Do you drink alcohol? YesNo
According to you, do you drink enough water? Yes NoI do not know
How many glasses of water do you drink every day?
Do you exercise regularly? Yes No
How many times per day or per week?
How many hours do you sleep at night?
Do you consider your sleep to be conducive to recuperation? YesNo
What position do you sleep in?
Is your mattress relatively firm? 
How old is it? 
What type of pillow do you have? 
How old is it? 
Do you consider your diet to be healthy? Yes No
Are you vegetarian?
Do you eat fish and if so, how often?
How many portions of cow’s milk do you drink every day?
Do you often eat…
 meals prepared and cooked at home  meals at a restaurant
 meals that are prepared in advance by a store or a company?
 
Systems Review
 
Do you suffer from difficulties with…
 Your eyes – recurrent infections, cross-eyed, near-sightedness, far-sightedness…
 Your ears – ear infections, hearing dificulty, constantly hearing sounds…
 Your nose or your sinuses – congestion, frequent colds, sinusitis, allergies…
 Your mouth or your throat – abcesses, frequent sore throats…
Your digestion – acid reflux, difficulty digesting certain foods, allergies…
Your elimination – frequent diarrhea or constipation, difficulty/pain on urination…
Your lungs and respiration – difficulty breathing, chronic bronchitis, COPD, asthma…
Your heart – heart problems, feeling of palpitations, high or low blood pressure…
Your nervous or vascular system – headaches, migraines, light-headedness, vertigo, loss of consciousness, trembling/shaking, numbness, memory loss…
Your skin – frequent irritations, unusual pimple or plaques, rash…
Your osseous and articular systems – articular pains…
Your emotional health – towards work, home, school, finances, pregnancy, your role as a natural caregiver, loss of a loved one…
Your psychological health – Depression, irritability, fatigue, nervousness…
Not too stressed?
Your fertility – difficulties to conceive, miscarriages…
Your genital system –
For women: menstrual pain, symptoms of menopause…
For men: erectile difficulties, lowering of libido…
What are your hobbies and/or your passions?
 
Expectations
 
What are your expectations by coming here ?
Do you wish to receive care to …
Reduce symptoms/Patch, only to diminish pain
To restore your health
To maintain your health
To increase your level of well-being (better-being)
 
Health and Quality of life are among the most precious things in this world – YOUR
HEALTH AND YOUR FAMILY’S HEALTH. Chiropractic is there for You. The adjustments
will help you to express your full potential of life. When you receive a chiropractic adjustment, the work has just begun. During the hours and days that follow your adjustment, your Innate Intelligence will continue to work by using the information received during the adjustment in order to make you better and so that your full healing power will be released. At the Maison Chiropratique Petits et Grands, we do not treat any condition or disease. We adjust people and the body decides, with its Innate Intelligence, what needs to be done, and what can still be done. Hence, we work in harmony with your inner wisdom. However, this process implies that you take back control of life and of your health, and that you accept to invest yourself in assisting “Dr You”.

I recognize that the given information is exact to the best of my knowledge and I consent
to receive any necessary examinations.
 
 
     
Signature   Date
 
 
 
 

 

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