Chiropractic Intake From | The Knee Clinic Calgary

Physical History

Please mark a 1 beside any conditions you have had in the past
Please mark a 2 beside any condition that you have presently

Musculoskeletal system

Neck Problems

1
2

Upper back problems

1
2

Shoulder problems

1
2

Elbow/wrist problems

1
2

Low back problems

1
2

Knee problems

1
2

Ankle/foot problems

1
2

Arthritis

1
2

Nervous system

Numbness

1
2

Loss of feeling

1
2

Headaches

1
2

Dizziness

1
2

Fainting

1
2

Confusion

1
2

Depression

1
2

Forgetfulness

1
2

Cardio-Vascular-Resp.

Chest pain

1
2

High blood pressure

1
2

Difficult breathing

1
2

Persistent cough

1
2

Coughing phlegm/blood

1
2

Lung problems

1
2

Varicose veins

1
2

Diabetes

1
2

Hypoglycemia

1
2

Genito-Urinary system

Painful urination

1
2

Excessive urine

1
2

Scanty urine

1
2

Discolored urine

1
2

Gastrointestinal system

Poor appetite

1
2

Excessive hunger

1
2

Abdominal pain

1
2

Excessive thirst

1
2

Nausea/vomiting

1
2

Diarrhea

1
2

Constipation

1
2

Bloody/black stool

1
2

Liver/gallbladder trouble

1
2

Weight trouble

1
2

Ear, Eyes, Nose, Throat

Eye problems

1
2

Vision problems

1
2

Ear discharge

1
2

Ear pain

1
2

Ear ringing

1
2

Hearing loss

1
2

Sore throat

1
2

Allergies

1
2

Hoarseness

1
2

Female

Premenstrual syndrome

1
2

Abnormal vaginal discharge

1
2

Abnormal vaginal bleeding

1
2

Pregnancy

1
2

Breast pain, and/or lumps

1
2

Your first visit to the office includes both an initial consultation as well as an office visit. At the discretion of the doctor, your first visit may not consist of actual treatment.

Attire/Hygiene

Some treatments necessitate direct skin contact. Please bring shorts to each appointment and bathe before attending your appointment.

Please refrain from wearing any cologne, perfumes or scented lotions while in the clinic.

Step 1 of 3

Personal Information

Family Doctor (GP)

Emergency Contact

Other Information

Health Information