Our purpose is to support each individual in achieving their optimum health.

Birth Sex *

Male

Female

Parent name for children under 18

Claimant's Authorized Representative (if applicable)

Emergency Contact Name and Phone Number *

Marital Status *

Number of Children *

Occupation/ Employer

How did you hear about us? *

Is this appointment in relation to any of the below? *

Recent Motor Vehicle Accident

Recent Work Injury

None of the above

Is this appointment regarding a New MVA claim (Haven't been seen/treated by any practitioner/specialist since the accident) OR part of a current active MVA claim (Already being treated by one of us/another practitioner for the above mentioned accident)

New MVA claim

Active MVA claim

Who is responsible for your account? *

If "other" is responsible for your account

Alberta Health Care # *

Are extended health care benefits available? eg. Blue Cross or similar Employee benefit plans *

Yes

Extended Health Care Plan Details (if applicable)

Name of Insurance Company
Policy Number:
ID Number:
Policy Holder (If not yourself):
Policy Holder DOB (If not yourself):
Policy Holder ID Number (If not Yourself):

Car Accident Information

Auto Insurance Information

Date of Accident
Location of Accident
City
Time
Insurance Company Name
Adjuster Name
Adjuster Email
Adjuster Phone #
Policy #
Claim #
Was a police report made?
Were you wearing a seat belt?
Approximate speed of your car
Approximate speed of other car
Make/type of car you were in
Make/type of other car

Were you

Were you struck from

Behind

Right Side

Left Side

Front

How did the accident occur?

How did you feel immediately after the accident? If the injury was not noticeable right away, when did you notice any problems?

Have you received any first aid or other treatments for this injury?

Did you receive any diagnostic tests regarding this injury. If so provide details and location of test

Were you hospitalized?

Yes

Were you off work because of this injury?

If yes, the first day you were unable to work was:

Have you returned to work?

Yes

If yes, on what date?

List the extent of injuries as you know them

Did any part of your body hit the car?

Yes

If yes, please describe

Were you knocked unconscious?

Yes

Check symptoms you have noticed since the accident

Are you currently employed or engaged in training activities?

If seasonal, please provide job title

Are you currently receiving medical or rehabilitation benefits related to another motor vehicle accident

Yes

Work Injury Information (WCB)

Company Phone Number:

Did the injury/condition develop over time?

Yes

Describe how and when the injury occurred

Have you missed time off of work beyond the date of the accident?

Yes

Has there been any diagnostic imaging completed (X-ray, ultrasound, MRI etc)

Yes

Purpose of this appointment: *

Where is your primary complaint? *

Type of pain: *

If Other Please Explain Type of Pain:

Please rate your pain on a scale of 1 - 10, with 10 being the worst: *

Is your pain: *

If Other Please Explain

When did your condition begin? *

What worsens your condition? *

What improves your condition? *

Have you had this problem in the past? *

Yes

Treatments received for this complaint: *

Have you ever received Chiropractic care in the past? *

Yes

Have you ever received Physiotherapy care in the past? *

Yes

Have you ever received Massage Therapy in the past? *

Yes

Please mark any other concerns that apply to you, with their severity level on a scale of 1-10(10 being the worst), and their frequency.

Headaches - Frequency

Neck Pain - Frequency

Midback Pain - Frequency

Low Back Pain - Frequency

Shoulder Pain - Frequency

Hip Pain - Frequency

Foot Pain - Frequency

If Other concerns please list:

Other Pain Frequency

Please mark any hospitalizations/ surgeries: *

List other surgeries

Have you had any major accidents, falls, broken bones *

Please mark the following problems you have had *

Current Medications for: *

Family History: *

If Other, please list other family history

General and Spinal Health History

Previous severe fall or injury

Been in a motor vehicle accident – with or without injury

Experienced change in weight in the past year

Broken bones

Concussions

Participated in contact sports

Been taught proper lifting and body mechanics

None of the above

Were you a breach baby? *

Yes

Unsure

Were forceps used? *

Yes

Unsure

Any complications at birth? *

Yes

Unsure

Were you born by Cesarean? *

Yes

Unsure

Was the delivery long or difficult? *

Yes

Unsure

Were normal baby milestones met? Ex: crawling walking, talking *

Yes

Unsure

Childhood and Adolescent History

Did you have Colic? *

Yes

Unsure

Were you frequently on medications? *

Yes

Unsure

Any back or neck pain as a child or youth? *

Yes

Unsure

Any broken bones? *

Yes

Unsure

Were you taught how to take care of your spine? Posture, bending, lifting. *

Yes

Unsure

Exercise/Activity level *

Poor

Average

Good

Diet *

Poor

Average

Good

Stress level *

Low

Average

High

Fruit and Vegetable intake *

Poor

Average

Good

Quality of sleep *

Poor

Average

Good

Alcohol Intake *

None

Mild

Moderate

Caffeine Intake *

None

Mild

Moderate

Smoking or Vaping *

None

Mild

Moderate

Water Intake *

None

Mild

Moderate

White Sugar Intake *

None

Mild

Moderate

Vitamins *

None

Basic

Extensive

Would you be willing to do a Google review to help others find a great health team? *

Yes

People go to Chiropractors and Therapists for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief care).

Others are interested in having the cause of the problem, as well as the symptoms corrected and relieved (Functional/Rehabilitative care).

Still others want their bodies brought to the highest state of health possible (Wellness care). Your doctor/therapist will weigh your needs and wishes when recommending your treatment program.

Please mark the type of care desired, so that we may be guided by your wishes whenever possible *

Relief

Rehabilitative Care

Wellness Care

Mark here if you want the Doctor/Therapist to select the appropriate care for your condition

I confirm the above information is accurate and I give my consent to be examined.

Thank you for choosing our clinic for your health care needs!

Car Accident Information

Work Injury Information (WCB)

Current History

Past History

General and Spinal Health History

Birth History

Childhood and Adolescent History

Lifestyle