Dr. K.A. Suek | Dr. Brian Wolfs | Dr. C. Greenwood | Dr. J. Duliunas

| 1900 Minnesota Ct. Unit 110, Mississauga, On., L5N 3C96 |

Phone: 905-567-8535 | Fax: 905-567-8232

Thank you for choosing our office!

To ensure your visit with us is a pleasant one, here are the procedures you can expect upon arrival

Paperwork - Please complete this questionnaire and your health history to help us to get to know you. The doctor will use this information to help formulate recommendations for your care.

Consultation - You will meet the doctor and our New Patient Advocate. The doctor will review your health history and determine if yours is a chiropractic case. You will be informed of any of the fees for office procedures before they are performed.

Examination - Standard physical, orthopedic, neurological, and chiropractic tests will be performed to determine the cause(s) of your subluxations.

Spinal Images - Necessary views may be taken to visualize the location of any spinal problems, neurological interferences, reveal any pathologies, and make your chiropractic care more precise.

Correlation - Before proper care can be rendered; the doctor will study your examination findings. Later, you will see x-rays, review your findings and receive specific care and recommendations from the Doctor.

CONFIDENTIAL PATIENT INFORMATION AND CASE HISTORY

How would you like to be addressed?

Mr.

Ms.

Miss.

Mrs.

Your Relationship To Patient *

Marital Status

Who may we thank for referring you to our office?

Do you have extended health insurance?

Yes

Name and number of Medical Doctor:

Annual health insurance coverage for chiropractic?

Females Only: Are you pregnant?

Yes

SOURCES OF SPINAL STRESS

What is your major complaint for which you are seeking chiropractic care?

Birth – with respect to your own birth process, please check all that apply:

Did your mother sustain any falls, accidents, or injuries during pregnancy?

Yes

Not Sure

Childhood accidents/injuries—check all that apply:

Adulthood accidents/injuries:

Please list any major operations/illnesses you’ve had and their approximate dates.

Auto Accidents: Have you ever, even as a passenger, even if you did not think you were hurt, been involved in a car accident or near collision?

Yes

If you answered yes to the above question please fill in:

Description of accident

Injury after accident

Physical Examination by

X-rays taken (approximate date)

. Please list any medication (prescription or over-the-counter) that you’ve taken in the past 6 months along with their frequency.

Primary Daily Activities – constant poor posture will lead to spinal stresses.

The following questions apply to the major concern that you have come in for.

Where is the location of your major complaint?

How long has this been going on?

Spinal stress can generate different types of discomfort throughout the body. How would you describe what you feel?

Spinal stress can also choke on the nerves to cause the pain to travel to different parts of the body. For example, neck pain can travel down into the shoulders or arms; low back pain can travel down into the legs. Have you experienced any travelling pain?

Yes

If yes, from ___to____ (indicate which sides of the body)

Spinal stress can put pressure on and off the spinal cord and nerves, causing symptoms to come and go over time. Is your condition CONSTANT or INTERMITTENT?

Constant

Intermittent

What have you found that aggravates your symptoms?

What have you found that relieves your symptoms?

On a scale of 1-10 how you would rate your discomfort:

Who have you already seen in an attempt to correct this problem? (ex. Chiropractors, physiotherapists, etc)

How has it affected your life? What are you hoping to improve in your life with chiropractic care? That is, what would you like to start doing or do more of if you were feeling 100%?

How committed are you to achieving optimal health?

What is most important to you in a relationship with our clinic? (Please check only one)?

ABOUT YOUR HEALTH

The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nerve system, that have resulted in your lowered state of health. At your report of findings, Dr. Janina will outline a course of care to begin to correct these layers of damage and recover your innate health potential.

Past Health: Have you ever suffered from any of the following conditions?

Thyroid trouble

Yes

Diabetes

Yes

Currently

High Blood Pressure

Yes

Heart disease

Yes

Venereal Disease

Yes

Stomach ulcers

Yes

Emotional problems

Yes

Cancer

Yes

Currently

Epileptic seizures

Yes

Present Health: Are you presently affected by any of the following? (Within the past 3 months)

Please check the boxes: O - OCCASIONAL F - FREQUENT C - CONSTANT

MUSCLE AND JOINT

Spinal curvature

Faulty posture

Painful tailbone

High blood pressure

Low blood pressure

Pain over heart

Rapid heart beat

Poor circulation

Yes

Swelling of ankle

GENERAL SYMPTOMS

Fever/chills/sweating

Loss of Balance

Eyes, Ears, Nose, Throat

Numbness or pins & needles in arms/hands, legs/feet

Ringing in ears

Blurring of vision

Loss of memory

Loss of concentration

Irritable/nervousness

Decreased energy/fatigue

Spitting up phlegm/blood

Nausea or vomiting

Kidney trouble

Bladder trouble

Increased urination

Painful urination

Waking at night to urinate

Blood in urine

Painful menstruation

Irregular periods

Passed menopause

Birth control pills

Yes

Menopausal symptoms

Date of last menstruation

By providing my phone number and email address, I agree to receive text messages and emails from the business.

| 1900 Minnesota Ct. Unit 110, Mississauga, On., L5N 3C9 |

Phone: 905-567-8535 | Fax: 905-567-8232