PART 1 - PATIENT CONTACT INFORMATION · Evaluate your feelings with respect to your quality of life : Your personal life Your wife/husband or “significant other” Your romantic

1. Most patients are referred to our clinic by a caring family member or friend.What made you decide to visit our clinic?

2. Research shows that your spine should be checked regularly.How many times have you consulted a chiropractor?

3. When was your last complete spinal examination?

4. Spinal tension causes decay and degeneration which results in grinding or cracking.Do you ever hear noises when you move your head or neck?

5. Spinal tension can make you feel like you need to twist, stretch or crack your neck or back.Do you ever feel the need to crack or pop your neck or lower spine?

6. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture? (Poor - 1 2 3 4 5 6 7 8 9 10 - Excellent)

YES NO

YES NO

1 2 3 4 5 6 7 8 9 10

Name:

Address:

Date of Birth: Occupation: Children:

I agree to be on Clinic Maintenant’s mailing list.

Home Phone: Work Phone: Cell Phone: E-mail Address:

City:

Status:

Province: Postal Code:

PART 1 - PATIENT CONTACT INFORMATION

PART 2 – GENERAL QuEsTIONs

WebsitePresentation Sign - Passing byFamily member or friendName:

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YES NO

1. Do you have a current health/life concern or symptom?

If YES, please describe:

When did it begin?

How and why did it manifest itself?

If NO, please describe the reason you are consulting our clinic and then skip directly to PART 4:

2. Is your problem a work-related accident or due to a road-accident?

If YES, please write down the date of the accident:

YES NO

7. Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days. (Low - 1 2 3 4 5 6 7 8 9 10 – High)

8. Prescription medication may cause serious side-effects, hide the severity of health problems and hinder the body’s ability to heal.What medication are you currently taking?

9. Car accidents and work-related injuries can cause serious damage to the spinal cord.Are you consulting our clinic because of a work-related injury or accident?

If YES, please write the date when it occurred :

1 2 3 4 5 6 7 8 9 10

PART 2 - GENERAL QuEsTIONs (CONT’D)

YES NO

PART 3 – YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE

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3. Have you done anything about this concern or been given any advice or treatment for it?

If YES, describe what was done.

4. Have any other family members had the same or similar concerns?

If YES, what did they do about it?

Did it seem to work?

5. How aware are you of your symptom / concern in the morning when you get up? (0 = not at all / 3 = extremely aware)

6. How aware are you of your symptom / concern during the day? (0 = not at all / 3 = extremely aware)

7. How aware are you of your symptom / concern at the end of the day?(0 = not at all / 3 = extremely aware)

8. How are are you of your symptom / concern during the night?(0 = not at all / 3 = extremely aware)

9. Is there an activity that you do, during which you totally, or almost totally forget about this condition ?

10. Why do you think this is happening, or continues to happen to you?

11. Do you think this is the only reason?

If NO, what else may be the cause?

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

YES NO

YES NO

PART 3 - YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE (CONT’D)

YES NO

YES NO

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12. Are you doing anyhting differently in your life because of this symptom / concern?

If YES, please describe:

13. If it were to go away tomorrow, how would your life be different?

14. Please grade how the concern / symptom affects the folllowing aspects of your functioning or quality of life: (0 = does not seem to affect me, 1 = slightly affects me, 2 = moderately affects me, 3 = extremely)

Work

Recreation

Rest / sleep

Social life

Walking

Sitting position

Exercising

Eating

Relationships

Comments:

15. If the situation didn’t change or evolve, how do you think it would affect your life in the next 5 years?

16. If we could work together to help you solve this problem, how would your life be different in the years to come ?

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

PART 3 - YOuR sYMPTOMs AND HOW THEY CAN INFLuENCE YOuR LIFE (CONT’D)

YES NO

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1. Your BirthDid your mother experience any problems during her pregnancy with you? Check all that apply: Falls Illness Difficult Not sure

Comments:

Was your birth...Check all that apply:

Traumatic

Cesarean

Breech

Forceps or suction

Cord around the neck

Prolonged

2. Falls Check all that apply, indicating age and year: Crib / Carriage Age:

Stairs Age:

On ice Age: From a tree Age:

3. General Physical TraumaCheck all that apply, indicating age and year:

Lost consciousness Age:

Use of crutches or a cane Age:

Broken bones or sprains (Describe): Age:

PART 4 - PHYsICAL sTREss HIsTORY

Very fast

Natural

Induced

Home

Hospital

Birthing Centre

Jungle gymsAge:

Skiing / SnowboardingAge:

Other falls (Please describe.)Age:

CombatAge:

Physical fightsAge:

SportsAge:

Extensive dental work / OrthodonticsAge:

Other (Describe):Age:

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4. Accidents (big or minor, either as a driver or passenger) Check all that apply indicating age and year :

Car Age:

Motocycle Age:

Bus Age:

Train Age:

5. Daily ActivitiesCheck all that apply :

Sitting Standing Walking Desk work Phone Sports

6. Medical HistoryCheck all that apply, indicating age and year :

Hospitalisation - Reason? Age: Surgery - Why? Age:

Chemotherapy Age:

Radiation Age: Casts or corsets Age:

Spinal / Neck Brace Age:

PART 4 - PHYsICAL sTREss HIsTORY (CONT’D)

BikeAge:

AirplaneAge:

Other:Age:

Comments:

ExercisingComputer workWatching TVDriving / CommutingPlaying an instrument Reading for long periods

Mechanical workHeavy liftingContactsGlasses

Comments:

Corrective shoes, bars, liftsAge:

PhysiotherapyAge:

Spinal taps, injectionsAge:

Comments :

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7. Have you or a family member ever suffered a serious illness?

8. Do you have a family doctor?

9. When was your last medical exam? Please write the date of the exam:

What were the results?

10. (For women.) Are you pregnant?

If YES, please indicate the number of weeks:

PART 4 - PHYsICAL sTREss HIsTORY (CONT’D)

YES NO

YES NO

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Alcohol Coffee / caffeine Processed food Artificial sweetners

Refined sugar Sodas Tap water

4. List all current and past medication and include reasons and length of time you were taking them.

5. Do you work with or have you worked with or ever been exposed to :

Chemicals Fumes Dust Powder / particles Smoke Other substances

6. Do you consume :

1. Birth stress

During your mother’s pregnancy, did she :Check all that apply :

Use prescription drugs Use non-prescription drugs Smoke

Consume alcohol / drugs I don’t know

2. During your birth, was your mother :Check all that apply :

Conscious Semi-conscious Unconscious

Given spinal anesthesia Given chemicals to alter or induce labour I don’t know

3. General Chemical stress : Are you taking or have you ever taken :Check all that apply :

Prescription drugs Over-the-counter drugs Antibiotics

Other drugs Tobacco

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PART 5 - CHEMICAL sTREss HIsTORY

7. Describe your diet :

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1. Were you incubated or isolated after birth?

YES NO

2. Were you :

Bottle-fed Nursed Both

3. Past General Emotional Trauma

Check all that apply and note the severity (mild, moderate or extreme) :

PAST PRESENT MILD MODERATE EXTREME

Childhood

Personal relationship

Change of job / career

School

Divorce / separation

Change of lifestyle

Recreational

Work-related

Commuting

Loss of loved-one

Parents’ divorce

Abuse

Family

Financial

Stress of being sick / ill

Comments :

PART 6 - EMOTIONAL sTREss HIsTORY

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1. How would you rate your emotional mental health?

Excellent Good Fair Poor Getting better Getting worse

2. How would you rate your overall quality of life?

Excellent Good Fair Poor Getting better Getting worse

3. Have you pursued other avenues of growth, healing or personal development? Check all that apply :

Chiropractic Acupuncture Massage / Bodywork Homeopathy Psychotherapy Ayurvedic Medecine

Osteopathy Physical Therapy Aromatherapy Energy Work Rebirthing Sound / Light Therapy

4. What aspects of your life do you like, bring you joy or help you to feel better about yourself?

5. What particular factors or elements about your life experiences (family, work, recreational, past injuries, genetics, dietary programs, exercises, outlook, etc.) do you feel impair your opportunity to experience full health and wellness?

6. Which of the following do you practice regularly?

Exercise - Times per week : Yoga - Time per week : Chi Gong - Times per week :

Movement / Dance - Times per week : Meditation - Times per week : Prayer - times per week :

7. List any herbs, nutritional supplements or natural remedies you regularly take:

8. When stressed, how do you “centre” yourself or “re-group”?

PART 7 - LIFEsTYLE PROFILE

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2. Mental / Emotional state Rate the following questions in terms of frequency :

Feelings of distress when pain is present

Negative or critical feelings about yourself

Moodiness, temper flare-ups or outbursts of anger

Feelings of depression, lack of interest

Over-reacting to life stresses

Being overly worried about small things

Feelings of vague fears or anxiety

Difficulty thinking or concentrating or indecisiveness

Difficulty falling asleep or staying asleep

Experience of recurring thoughts or dreams

PART 8 - WELLNEss AND QuALITY OF LIFE suRVEY (CONT’D)

NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY

1. Physical state How often do you experience the following symptoms :

Physical pain (neck/back ache, sore arms/legs, etc.)

Feeling of tension, stiffness or lack of flexibilty

Fatigue, lack of energy

Colds, flu

Headaches

Heartburn, indigestion

Nausea, constipation

Menstrual discomfort

Allergies, skin rashes

Dizziness, light-headedness

Accidents, near accidents, fall-ing or tripping

Ease of recovery from injury

Restricted or shallow breathing

NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY

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4. Life Enjoyment Rate the following statements with respect to frequency :

PART 8 - WELLNEss AND QuALITY OF LIFE suRVEY (CONT’D)

Openness to guidance from your ‘inner voice’ or intuition

Experience of peace, relaxa-tion, ease or well-being

Presence of positive thoughts about yourself

Interest in maintaining a healthy lifestyle

Feeling of being open, aware and connected when relating to others

Confidence in your abilty to deal with adversity

Level of compasison for and acceptance of othersExperience feelings of joy or happiness

Experiencing gratitude

Satisfaction with your sex-lifeSatisfaction with your leisure activitiesTime dedicated to the things that you like to do

NEVER RARELY OCCAsIONALLY CONsTANTLYREGuLARLY

3. stress Evaluation Evaluate your stress with respect to the following :

Family

Significant Other

Physical Health

Finances

Sex Life

Work or School Coping with daily problems

NONE sLIGHT MODERATE ExTENsIVECONsIDERABLE

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5. Overall Quality of LifeEvaluate your feelings with respect to your quality of life :

Your personal life

Your wife/husband or“significant other”

Your romantic life

Your job

Your co-workers

The work you actually do

Handling problems in your life

What you are actually ac-complishing in your life

Your physical appearance - the way you look

Your abilty to adapt to change in your life

Overall contentment with your life

uNHAPPY MAINLY DIssATIsFIED MOsTLY MIxED HAPPYsATIsFIED