Woodgrove Pines Clinic - Chiropractor & Multi-Discipline Wellness Professionals In Nanaimo BC,

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Patient Intake Form

New form editor - use the controls on right to alter or add to this form.

First Name *

Last Name *

Date

Street Address

City/Province

Postal Code

Phone (Hm and/or Cell)

Phone (Bus)

Email Address

Date of Birth

Occupation

MSP No.

Is This Covered By?

DVARCMPNot Applicable

Is this visit the result of an accident?

YesNo

If Yes, is it:

ICBCWCB

Marital Status (please select from drop down menu)

No. of children and their ages:

Do your children live with you?

Emergency Contact - Name and Phone No.

Family Doctor - Name and Phone No.

How did you hear about us? (please select from drop down menu)

If you selected "other" please describe:

What is your main area of concern? Have you had these symptoms before?

What activities or movements aggravate or relieve your symptoms?

Is this condition getting:

betterworseconstantcomes and goes

Is this condition interferring with your:

worksleepdaily routine

If yes, please describe:

Have you had any previous accidents or injuries?

YesNo

If yes, please describe:

Are you currently taking any medication or supplements?

YesNo

If medications: name, amount and what you understand it to be prescribed for.

Vitamins, Minerals and Herbs; list brand names, amounts taken and specific reasons why (if you know).

Other Practitioners you are seeing; please indicate name and type of practitioner, along with treatment received.

Any previous illness or condition?

YesNo

If yes, please describe:

Have you had any recent/past surgeries or trauma? If so, what was it and when did it happen?

Do you smoke?

YesNo

Do you drink coffee?

YesNo

If yes, how many cups a day?

Recreational Drugs?

YesNo

Do you drink Alcohol?

YesNo

If yes, how much?

How many cups of water do you drink per day?

Work: describe your current job. Is it sedentary? Highly physical? Please use a percentage; for example, 25% sitting, 50% walking and 25% lifting boxes of about 20 lbs.

Do you stretch? If so, how often and what areas?

Diet - Are you on a specific diet?

YesNo

If yes, please describe. If no, please describe a typical weekday/weekend breakfast, lunch, dinner and snacks:

Exercise Program (Type and Frequency):

Women - Are you pregnant?

YesNo

If yes, when are you due?

Do you wear:

Sole LiftsInner SolesArch Supports

Do you have any of the following? (check all that apply)

anemiaarthritisasthmabruise easilycancerchest painscold hand/feetdepressiondiabetesdisc problemsdizzinessfaintingfatiguesheadachesheart diseasehigh blood pressurelow blood pressuremental/emotional disordersnervousnesspins and needlesringing in earsseizuresshortness of breathsinus troublespasmsstomach problemsstrokeswollen jointsT.B.throat tightnesstwitching facevaricose veinsother

If you selected "other", please describe:

Family history with any of the above?

YesNo

Other comments?

Enter the verification code in the box below.

Verification Code: *

Top

New Chiropractors!

Please Welcome
Dr. Derek Brown D.C.
and
Dr. Audrey Cameron B.Sc. D.C.
to our Health Care team!
Dr. Brown and Dr. Cameron will be in the office weekdays and Dr. Brown will also be in on Saturdays. Book your appointment today!

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