Return Foster Family Chiropractic
Adult History Form
           When complete, please print this form and bring it with you to your first appointment.
       Should you require additional space to complete the form, please refer to Additional Comments near the bottom.
Patient Information
First Name Last Name
Street Address Apartment
Town/City Province Postal Code
Home Phone Work Phone  
E-Mail
Birth Date   Age Sex
Marital Status
Occupation Employer
Spouse's Name Occupation
No. of Children
Height cm in Weight kg lbs
How did you hear about our office?
Were you referred to this office? Yes No
      If yes, by whom?
Medical History
Purpose for contacting us?
     
How long have you been experiencing this?
     
Is it getting better or worse over time? Better Worse
Other health care professionals consulted for this problem
     
Have you been hospitalized for this problem? Yes No How many days?
Are you content with your present level of health? Yes No
      If not, what aspect would you change?
     
Is your complaint the result of a work injury or car accident? Yes No
      If yes, please explain
     
Other health problems?
     
Select any of the following that you now or have experienced in the past:
Anemia Allergies Arthritis Asthma Cancer
Anxiety / Panic Dizziness Diabetes Tension Insomnia
Headache Sinus Trouble Heart Trouble Vision Problems Numbness / Tingling
Backache Growing Pains Neck Aches Depression Colic
Epilepsy Hepatitis Nausea / Vomit Rheumatism Nervousness
Digestive Problems Loss of Memory Muscular Dystrophy Multiple Sclerosis Leg Pain
Shortness of Breath Extreme Fatigue Chest Pain High Blood Pressure Feet / Hands Cold
Ear Infections Ears Buzzing / Ringing Limited Neck Motion Limited Midback Motion Limited Low Back Motion
Head & Shoulders Tired and Heavy Attention Problems - ADD/ADHD
Other Specify Other
Please Describe:
Past Injuries
     
Prior Surgery
     
Prior Hospitalizations
     
Prior Motor Vehicle Incidents
     
Medication Use (in childhood or adulthood)
     
Have you been treated by a physician for any condition(s) in the past 12 months?      Yes No
      If yes, please explain.
     
Are you currently taking any medications?      Yes No
      If yes, please list.
     
Are you presently taking any herbal or vitamin supplementation?      Yes No
      If yes, please list.
     
How often do you exercise?
     
What type of exercise?
     
Do you smoke?      Yes No
Previous Care
Have you ever had chiropractic care in the past?      Yes No
      If so, when?
Reason for Care
     
Doctor Seen:
     
Additional Comments
     
Consent for Care
Doctors of Chiropractic, Medical Doctors and Physical Therapists using manual therapy treatments for patients with neck problems are required to explain that there have been rare cases of injury to a vertebral artery as a result of treatment. Such an injury has been known to cause stroke, sometimes with neurological injury. The chance of this happening is extremely remote, approximately 1 per million treatments.

Appropriate tests will be performed on you to help identify if you may be susceptible to that kind of injury. The doctors use a variety of techniques in this office; many techniques do not involve manual therapy. If you have any questions about this, please do not hesitate to speak with the doctor.

I understand that the spinal adjustments offered in this office are not a replacement for any form of treatment provided by other types of practitioners. I understand that I am not being treated for any symptom or condition other than spinal subluxation. This office offers chiropractic as a form of health and wellness care, to promote the natural mechanisms for self-healing and empowerment.

I have read and understood the above statement, accept the risk, and hereby consent to chiropractic care.

Date  
Signature of Patient / Guardian
Please complete this form prior to arriving at our office. If you have any questions, please do not hesitate to contact our office at 905-898-8098, or wait until your appointment time. We are excited that you have chosen Dr. Laura Foster & Associates for your chiropractic care. It is our pleasure to welcome you and your family to the most natural form of health care, chiropractic.
Instructions for First Appointment
Our office utilizes the most advanced form of non-invasive diagnostic procedures available. Please refrain from intense exercise 6 hours prior to your appointment time, as well as avoiding heat/ice, caffeine and over-the-counter (non-prescription) medications. These may interfere with the quality of your diagnostic results. Please call if you have any questions.

We look forward to seeing you.