First Name *

Last Name *

Phone (mobile) *

Email *

Date of birth *

Age

Gender *

male

female

other

Marital Status

Married

Single

Address

Postal code

City

BC Personal Health Number

Occupation

Employer

How did you hear about Vida Chiropractic

Referral by a Client

Google Search

Facebook or Instagram Post

Saw our office

If referred, who may we thank for referring you?

Have you ever received Chiropractic Care?

Yes

Previous Chiropractor's name and approx date of last visit

The symptom(s) that have prompted you to seek care:

The cause of this problem

Work Injury

Motor vehicle Accident

Other injury

Long term problem

ICBC Claim # (if applicable)

Primary purpose of this appointment is to seek help with:

When did you first notice this problem

On a scale of 1 -10 (10 being the worst pain) how extreme is it?

1
2
3
4
5
6
7
8
9
10
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Does the pain radiate to other areas? If so, where?

How often do you feel it?

Constant

Comes and goes

If it comes and goes, how frequently is it a problem?

How would you describe the character of your pain?

Aching

Burning

Tingling

Cramping

Shooting

Stabbing

Stiffness

Throbbing

Nagging

Dull

Sharp

Numbness

What have you tried to relieve your symptoms?

Over the counter medications

Prescription medications

Homeopathic remedies

Ice

Heat

Acupuncture

Physical Therapy

Massage

Chiropractic

Other

Please check off the areas where you are experiencing your symptoms

Head and Neck

Head

Upper Neck into Head

Upper Neck

Mid Neck

Lower Neck

Lower Neck into Shoulder/Blade

Back Area

Upper Back

Shoulder Blade Area

Mid Back

Lower Back

Buttock

Further Describe the Location of your Symptoms (if necessary)

What relieves your symptoms?

What aggravates your symptoms?

Are there any other symptoms or health concerns that you have?

Previous Injuries?

Fractured or Broken Bones

Injured in an Accident

Spine or Nerve Disorder

Knocked Unconscious

Used Neck or Back Bracing

How does your current condition affect your daily activities? Please respond only for activites that it affects.

Sitting

Mild Affect
Moderate Affect
Severe Affect
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Rising out of a chair

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Standing

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Walking

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Climbing Stairs

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Bending Over

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Lying down

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Lifting Objects

Mild Affect
Moderate Affect
Sever Affect
No elements found. Consider changing the search query.
List is empty.

Looking over shoulder

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Reaching overhead

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Household chores

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Yard work

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Dressing myself

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Exercising

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Getting to sleep

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Staying asleep

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Getting In/Out of Car

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Concentrating

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Using a computer

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Driving a car

Mild Affect
Moderate Affect
Severe Affect
No elements found. Consider changing the search query.
List is empty.

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. How is your body functioning? Have you had any of the following?

Musculoskeletal

Osteoporosis

Current

Past

Foot / Ankle Pain

Current

Past

TMJ Pain

Current

Past

Elbow / Wrist Pain

Current

Past

Knee Pain

Current

Past

Hip Pain

Current

Past

Poor Posture

Current

Past

Scoliosis

Current

Past

Neck Pain

Current

Past

Back Pain

Current

Past

Shoulder Pain

Current

Past

Headaches

Current

Past

Neurological

Dizziness

Current

Past

Anxiety

Current

Past

Numbness

Current

Past

Pins and Needles

Current

Past

Sciatica

Current

Past

Carpal Tunnel

Current

Past

Cardiovascular

High Blood Pressure

Current

Past

High Cholesterol

Current

Past

Excessive Bruising

Current

Past

Angina / Heart Disease

Current

Past

Poor Circulation

Current

Past

Diabetes

Current

Past

Respiratory

Asthma

Current

Past

Sleep Apnea

Current

Past

Allergies

Current

Past

COPD

Current

Past

Sensory

Blurred Vision

Current

Past

Ringing in the Ears

Current

Past

Hearing Loss

Current

Past

Chronic Ear Infections

Current

Past

Endocrine

Frequent Infections

Current

Past

Hypoglycemia

Current

Past

Immune Disorders

Current

Past

Thyroid Issues

Current

Past

Swollen Glands

Current

Past

Low Energy

Current

Past

Genitourinary

Kidney Stones

Current

Past

Frequent Bladder Infections

Current

Past

Prostate Issues

Current

Past

Constitutional

Poor Appetite

Current

Past

Fainting

Current

Past

Weakness

Current

Past

Illnesses

Cancer

Current

Past

Heart Disease

Current

Past

Neurological Disorder / Injury

Current

Past

Stroke

Current

Past

Surgeries

Please list any surgeries you have had

Medications

Please list any medications or treatments you are currently taking

Family History

Please list history of any chronic/hereditary disease in your family

Social History

Alcohol Use

Daily
Weekly
None
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Tobacco Use

Daily
Weekly
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List is empty.

Exercise Frequency

Daily
A few times a Week
Weekly
None
No elements found. Consider changing the search query.
List is empty.

Pain Relievers

Daily
Weekly
Rarely
No elements found. Consider changing the search query.
List is empty.

Work Stress

Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

Financial Stress

Mild
Moderate
Severe
No elements found. Consider changing the search query.
List is empty.

I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.

I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.

I realize that an X-ray examination may be hazardous to an unborn child and certify that to the best of my knowledge I am not pregnant.

I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.

I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.

To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.