Adult Health Profile - Desktop Version
Date of birth (Month/Day/Year):
Home Address and Phone Number
Employer and Work Phone Number
Family Medical Doctor
Have you had Chiropractic care before? If so, when and by whom?
Spouse’s Name and Occupation
Children’s Name and Ages
Referred by (please include person’s name) Friend/FamilyM.D./D.CInternet/Ad
*If this is a Worker’s Comp case please tell us immediately.
Why this form is important:
Our office focuses on your ability to be healthy. Our goals are to first address the issues that brought you to this office, and second, offer the opportunity to improve your health potential in the future. In order to give you the best possible Chiropractic care, we will need to discover any ‘stresses’ that are placed on your body. Please take the time to fill out this form completely, as each question gives us a clearer picture of your current health status.
Reason for consulting this office
Wellness / Prevention Care – I wish to continue my Chiropractic Wellness Care. Just answer the following questions that apply.
Please describe your current problem, including the effect it has had on your life:
Please describe the character of your pain (check all that apply)
How often are the complaints present?
Constant (76-100%) Frequent (51-75%) Occasional (26-50%) Intermittent (25% or less)
When is the pain or symptoms worse:
When you wake up During the day After work In the evening After eating While sleeping
How bad is your pain or ache? (0= no pain, 10 = unbearable pain)
1 2 3 4 5 6 7 8 9 10
Since your problem began is the pain:
Increasing Decreasing Not Changing
When did your problem begin: (specific date if possible)
Do you sleep on your:
Back Stomach Left Side Right Side
Physical Activity at work:
Sitting more than 50% Light manual labour Heavy manual labour
General physical activity:
No regular exercise program Light exercise program Strenuous exercise program
How would you rate your stress level:
No Stress Minimal Stress Moderate Stress Greatly Stressed
Do you currently smoke? Yes No
If YES please indicate how many packs a day: Number of years:
Who else have you seen for this condition:
Please describe any falls, auto accidents or major injuries (include Month/Year, Type of accident):
Please describe any and all past surgery:
Please list ANY and ALL medication (prescription and over the counter): that you are currently taking:
Please Tick Any That Apply: PERSONAL HISTORY:
Aneurysm Osteoporosis Diabetes Thyroid Disease Arthritis Cancer Stroke
Heart Condition Hypertension Polio Asthma Psoriasis Others
If Others, please specify:
Please Circle Any That Apply: FAMILY:
Please check all symptoms or areas where you have problems, even if they do not seem related to your current problem.
Do you drink bottled or filtered water: Yes No
Do you belong to a health club or exercises regularly: Yes No
If you remember the details, what was your birth delivery like (eg – breach, c section, long):
Have you had any or all of your childhood vaccinations? All Some
Any reactions to vaccinations?
Please list all supplements and vitamins you take:
How would your rate your health: 1 2 3 4 5 6 7 8 9 10
How committed are you to improving your health: 1 2 3 4 5 6 7 8 9 10
Do you want to live to be a healthy 85 years old? Yes No
What is ‘being healthy’ to you (check all that apply)?
What is your goal or expectations with Chiropractic care:
For individuals enrolled in the Adult Health Profile form who receive Protected Health Information from their Doctors Informed Consent.
You acknowledge to Pike Chiropractic Healing Centre that you receive chiropractic care which enables your Doctor to transmit protected health information (“PHI”) and other data to your authorized email account on your computer device through the Pike Chiropractic Healing Centre website.
By signing below, you authorize your Doctor to utilize the Adult Health Profile form to transmit your PHI and Data to your authorized email account and agree to maintain such authorized email account on a secure basis, with a confidential User Name and Password. You further acknowledge and agree that any disclosure of your PHI and Data after transmission to you (“Transmitted PHI and Data”) through the website by the Doctor will be deemed to be under your custody and control thereafter, and the Doctor shall not have any responsibility by PHIPA for any further disclosure of such Transmitted PHI and Data to any party, whether authorized or unauthorized, which may occur.
Health is significant, but not necessarily serious – we will do what we can to make each visit stress-free.
Please enter your legal full name, email address and signature below. Then click on “Agree & Sign” to complete this step.
Leave this empty:
Signed by Dr. Robert Stewart Pike
Signed On: April 15, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Adult Health Profile - Desktop Version
Agree & Sign