D.B Todd Stewart, D.C.

Westbrook Family Chiropractic

#23, 1200-37 Street, S.W.

Calgary, AB T3C 1S2

Confidential Patient Health Record

Personal History

Name:          MrMrsMs

Last                                                  First                         Middle Initial

Address:

Street                              City                         Province                         Postal Code

Home Phone #: ()                    Birth Date://                    GenderMF

YY    MM    DD

Health Card #:                    Date of Appointment:

Employer:                    Type of Work:

Business Phone #: ()     ext.

Medical Doctor:          MD Phone #: ()

Reason for Appointment:

**Email address for appointment reminders

Is this condition the result of a car accident?                    YESNO

If yes, what was the date of the accident?//     Ins. Company:

YY    MM    DD

Does your case involve Worker’s Compensation? YESNO

If yes, what is the claim number:     SIN #:

Past Health History

Do you have any of the following conditions? Please check all that apply

arthritis      breathing disorders      high/low blood pressure      blood disorder      cancer/tumor      diabetes      epilepsy      H.I.V      heart disease      kidney disorder      liver disorder      psoriasis      thyroid disorder      hardening of arteries      lung disease      stroke      gall bladder disease

List all medications you are currently using

List all past surgeries including the dates

General Health

Please check all symptoms that have bothered you in the last six months

headache      neck pain/stiffness      poor appetite      vision problems      fatigue      back pain/stiffness      excessive appetite      loss of hearing      loss of sleep      shoulder pain      excessive thirst      ringing in ears      fever      arm/elbow pain      frequent nausea      frequent colds      sweats      wrist/hand pain      vomiting      frequent sinusitis      weight loss      hip pain      diarrhea      weight gain      knee pain      constipation      foot pain      abdominal cramps      clicking jaw      heartburn      general stiffness      bloody/black stool      colitis      numbness      chest pain      bladder trouble      weakness      shortness of breath      problems with urination      paralysis      irregular heartbeat      discolored urine      dizziness      varicose veins      prostate problems      fainting      ankle swelling      menstrual irregularities      seizures      menstrual cramps      tingling in limbs      breast lumps      menopausal symptoms      . . .

Informed Consent to Chiropractic Adjustments and Care I have received information about the proposed chiropractic treatment, any alternative courses of care, the benefits, the risks, and the side effects of the treatment and the consequences of not having the proposed treatment. I understand and am informed that, as in all health care, in the practice of chiropractic there are some very rare risks to treatment, including, but not limited to, muscle sprains and strains, disc injuries, and strokes. I do not expect the chiropractor to be able to anticipate or explain all risks and complications. I wish to rely on the chiropractor to exercise judgement during the course of the treatments which they feel at the time, based upon the facts then know, is in my best interests. My chiropractor has responded to all of my requests for information about the proposed treatment. I have read the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the described treatment procedures. I intend this consent to cover the entire course of treatment for my present condition.

Name:          Date: