Who do you want to recieve this form? Dr.Gus Tsiapalis Dr.Jacqueline Tsiapalis Dr.Josh Binstock Unsure
Personal Information
Name *
Address *
City *
Province *
Postal Code *
Home Phone # *
Cell Phone #
E-Mail *
Date of Birth *
Gender Male Female Other
Business/Employer
Type of Work
Business Phone #
Emergency Contact
Emergency Cell Phone #
Relationship
Referred By
Reason for contacting our office
What is your primary complaint?
Your Health Profile
Why This Form Is Important
As a full spectrum Chiropractic office, we focus on your ability to be healthy. Our goals are to address the issues that brought you to this office and offer you the opportunity of improved health potential and wellness services in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us profiles of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to health potential.
The Beginning Years (To Age 17)
Research is showing that most of the health challenges that occur later in life have their origins during the developmental years, some starting at birth. Please answer the following questions to the best of your ability.
Did you have any childhood illnesses? Yes No Unsure
Did you have any serious falls as a child? Yes No Unsure
Did you play youth sports? Yes No Unsure
Did you take/use any drugs? Yes No Unsure
DId you have any surgery? Yes No Unsure
Have you fallen/jumped from a height over three feet (i.e.: crib, bunk bed, tree)? Yes No Unsure
Were you involved in any car accidents as a child? Yes No Unsure
Did you suffer any other traumas (physical or emotional)? Yes No Unsure
Were you delivered using Vacuum Forceps C-Section Mom induced Naturally Unsure
Was there any prolonged use of medicine such as antibiotics or an inhaler? Yes No Unsure
As a child, were you under regular chiropractic care? Yes No Unsure
Rate your occupational stress level 1 (no stress) 2 3 4 5 6 7 8 9 10 (severe stress)
Please indicate any other traumas, impacts, collisions, and other injuries you have had
Adult Years (Age 18 to Present)
Do/did you smoke? Yes No
Do/did you drink alcohol? Yes No
Have you been in any car or work related accidents? Yes No
If so was your nerve system checked by a chiropractor afterwards? N/A Yes No
Have you had any surgery? Yes No
What kind of surgery?
Do you participate in extreme sports? Yes No
Did you have any impacts? Yes No
Do/did you play contact sports? Yes No
If so did you have your spine and nerve system checked regularly by a chiropractor? Yes No
Rate your personal stress level 1 (no stress) 2 3 4 5 6 7 8 9 10 (severe stress)
Medical History
Please check ALL of the following you might have EVER had even if you don't think they are related to the current problem: Arthritis Herniated Disc Numbness/tingling Depression Pain between shoulders Pinched Nerve Chronic Infections Low back/hip pain Walking problems Heart/vascular problems Frequent nausea Ulcers/heartburn Diabetes Pain/stiff in mornings Diarrhea/constipation Thyroid problems Upset stomach Mood swings Asthma/allergies Shortness of breath Buzzing/ringing in ears Liver/gall bladder problems Osteoporosis Bladder trouble/painful urination Cancer Menstrual irregularity Sexual dysfunction Blood pressure trouble Ankle swelling Decreased immunity/frequent colds Menstrual Cramps/Miscarriage(s) Chest pains/heart disease
List all medications you are taking and what for
For women: Are you pregnant? Yes No Trying Unsure N/A
Date of last menstrual period
Symptoms
If you have symptoms or complaints, briefly describe the chief area of complaint, including the effect it has had on your life
Please list medications you are taking for this condition
If you are experiencing pain, rate the level of pain 1 (low pain) 2 3 4 5 6 7 8 9 10 (severe pain)
Describe the pain you are experiencing Sharp Dull Comes & Goes Travels Constant
Since the problem started it is: About the Same Getting Better Getting Worse
What makes it worse?
It interferes with: Work Sleep Walking Sitting Hobbies Leisure
Name of other chiropractor seen for this problem:
Name of other medical doctor seen for this problem:
Name of other type of practitioner seen for this problem (include type of practice):
Please rate your level of commitment to resolving this/these problem(s) 1 (low commitment) 2 3 4 5 6 7 8 9 10 (high commitment)
If it's not 10, what stops you from full commitment?
Family Health Profile
At our office, we are not only interested in your health and well-being, but also the health and well-being of your family and loved ones. Please mention below any health conditions or concerns you may have. Your Family may be eligible for a free spinal checkup.
Children's Names
Spouse's Name
Mother/Father
Brother(s)/Sister(s)
Others
Thank you for submitting your form online!