| Form for the new Tall Ones |
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| 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 |
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| Present history |
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| 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. |
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Have you consulted another specialist for the same reason that brings you here?
Yes No
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If yes, who?
When?
And what was the result?
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| Have you ever received chiropractic care before?
Yes
No
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| If yes, who was your chiropractor?
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| Date of last adjustment:
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What did you like best about the care?
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What did you like least about the care?
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| Secondary objectives |
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| Are there any other reasons for seeking care that you would like to have addressed eventually? |
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| Life history |
| As best as you know, how did your pregnancy go (when your mother was pregnant with you) and your birth? |
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| Have you been a victim of birth trauma like |
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| Have you received routine vaccinations? Yes No |
| Date of most recent vaccine:
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| Have you suffered from adverse reactions following vaccination?
Yes
No
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| 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:
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| Do you suffer from imbalances like: |
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| Have you ever… |
| Had surgery? Yes No If yes, when and why?
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| Been a victim of falls, car collisions or other trauma? Yes No |
| If yes, when and describe briefly: |
| Broken any bones or lost consciousness? Yes No |
| If yes, when and describe briefly: |
| Been hospitalized? Yes No |
| If yes, when and why?
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| Family history |
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| 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?
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| If you have brothers, sisters and/or children, are they healthy? Yes
No |
| If no, specify briefly: |
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| Lifestyle |
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| How many times per day or per week?
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| How many hours do you sleep at night?
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| Do you consider your sleep to be conducive to recuperation? YesNo |
| What position do you sleep in?
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| 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?
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| Do you eat fish and if so, how often?
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| How many portions of cow’s milk do you drink every day? |
| Do you often eat… |
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| Systems Review |
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| 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… |
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| Your digestion – acid reflux, difficulty digesting certain foods, allergies… |
| Your elimination – frequent diarrhea or constipation, difficulty/pain on urination… |
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| Your lungs and respiration – difficulty breathing, chronic bronchitis, COPD, asthma… |
| Your heart – heart problems, feeling of palpitations, high or low blood pressure… |
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| 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… |
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| 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… |
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| Not too stressed? |
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| Your fertility – difficulties to conceive, miscarriages… |
| Your genital system – |
| For women: menstrual pain, symptoms of menopause… |
| For men: erectile difficulties, lowering of libido… |
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| What are your hobbies and/or your passions? |
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| Expectations |
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| What are your expectations by coming here ? |
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| 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) |
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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. |
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