Patient History Form

This form can be filled out and submitted online using the submit button at the bottom of the page. Upon reciept of the completed form, you will be contacted regarding an initial appointment.

To download the Patient History Form: Click here. When completed, please return to office by mail or fax. Upon receipt of history form, you will be contacted regarding an initial appointment.


Name:

Surname*

Middle Name

First Name*

Home Address:

Street Address*

City*

Province*
Postal Code

Telephone:

Home*

Work

Cell

Personal Information:

Date of Birth*
Year
Month
Day
Present age

Place of Birth

Marital Status
SingleMarriedDivorcedWidowed

Occupation

If Minor, Parents’ Names

Please List your Present Major Health Concerns* (starting with the most troublesome to you):

 
Concern
Since

1.

2.

3.

4.

5.

6.

Other Health Practitioners you are Currently seeing (or have recently seen):
Include: Family Doctor, specialists, physiotherapists, naturopaths, chiropractors, massage therapists, acupuncturists, herbalists, etc.

1.
2.

3.
4.

5.

ALL Current Medications (Prescription, Non-Prescription, Herbs, Vitamins, etc.). Please put each one on a new line.