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  • PERSONAL INFORMATION
     
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  • CONTACT INFORMATION
     
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  • HOW DID YOU HEAR ABOUT OUR OFFICE?

  • WHAT BRINGS YOU TO THE CLINIC?
     


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  • GENERAL HEALTH HISTORY
  • Past injuries can affect present health.
  • NERVOUS SYSTEM REVIEW
  • Your central nervous system (brain and spinal cord) is the master controller of your body. It controls the function of every cell, tissue, and organ. The connection between your brain and your body is through the spinal nerves: sensory, motor, and autonomic nerves. Please review the following system to determine if there may be a connection between your health profile and your nerve interference.
  • HEALTHY LIVING AND WELLNESS SELF-ASSESSMENT
     
  • Our centre is a wellness-oriented chiropractic practice for health-conscious, wellness-minded individuals and their families. We strive to improve the overall health and wellbeing of our patients, and take a proactive approach to health care so that our patients may live healthier, happier lives. To better understand your health and wellbeing, it is important that we review your lifestyle habits. Please score yourself according to how well you match the following statements: 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always
     
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  • WHAT DO YOU KNOW ABOUT CHIROPRACTIC?
  • PATIENT COMMUNICATION PREFERENCES
     
    Please select your preferred method of communication for appointment reminders, confirmations, missed visits, and rescheduling:
  • By choosing “Text message,” you give consent to receive appointment-related texts from our clinic, in accordance with Canadian Anti-Spam Legislation (CASL).
  • THANK YOU FOR FILLING OUR OUR CHIROPRACTIC NEW PATIENT HEALTH QUESTIONNAIRE!
     
    We look forward to helping you with your current health concerns and overall well-being. 
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