INFORMATION ABOUT YOU

Todays Date:sep_11_______
First Nam _Hamrajie______________________ Last Nam Singh
MaleFemale Birth date day__31___ month __05____ year__1976__ Current Age:37
Street Address:
City: ___Brampton_________________________ Province: _Ont____l6t4n5______
Postal Code:
Home #: _905 455 5998_________________ Work: __________________ Cell: 905
460 6412
Email address: smith.melisa79@yahoo.com

Occupation: __General Help______________________ Employer:
Spouses Name: ____________ # of children: __2__ Ages of children:
Are you pregnant: YexNo How did you hear about us?

Will you be claiming: Motor Vehicle Accident Yes x No WSIB x Yes
No
If yes: Injury/Accident Date: _________ Personal Injury Claim # (if
known)________________
CHIROPRACTIC HISTORY:
Have you been to a chiropractor before? Yes x No Date of last visit:
Name of last Chiropractor:
What are your health goals: Symptom Relief Wellness Care 100% Optimal potential!
MAJOR HEALTH CONCERN PLEASE FILL IN ALL AREAS: IF NOT APPLICABLE
PLEASE PUT N/A
What condition brought you to our office?
On a scale of 1-10 (10 being severe), how bad is the problem? __8__/10
When did it start? _________________________ How?
Is it getting better xgetting worse staying the same?
How would you describe the problem?
Are you taking medication for this condition? Yes xNo
If yes, which medication: ___________________________________________________Dose:
Please list ALL other medications you are currently taking:
What else have you tried that has not worked? :
Rate your stress level on an average day (circle number):
1 2 3 4 5 6 7 8 9 10
Very Low Moderate Very High
Please turn over and complete side two thank you
Your Health History
Please check all that you have experienced in the last 6 months:
Headaches Migraines Dizziness Sinus Problems Diabetes
Depression Neck Pain Shoulder Pain Ringing in Ears Menstrual Cramps
Ear infections Allergies Upper Back Pain Hand/Wrist pain High Blood
Pressure
Tinnitus Chest Pain Fatigue Mid Back Pain Fallen
Arches
Rib Pain Jaw Pain Heart Disease Low Back Pain Bladder Trouble
Knee pain Heartburn Diarrhea Hip Pain Bed Wetting
Ankle/knee pain Constipation Cancer Asthma Foot Trouble
Sleep Posture: side stomach back xrestless # of pillows _____ # of hours you sleep ____
Please fill out the following information on the above most serious conditions:
Condition 1:
On a scale of 1-10 (10 being severe), how bad is the problem? ____/10
When did it start? _________________________ How?
Is it getting better getting worse staying the same?
How would you describe the problem?
Are you taking medication for this condition? Yes No
If yes, which medication: __________________________________________________Dose:
What else have you tried that hasnt worked?
Aggravating factors:
Condition 2:
On a scale of 1-10 (10 being severe), how bad is the problem? ____/10
When did it start? _________________________ How?
Is it getting better getting worse staying the same?
How would you describe the problem?
Are you taking medication for this condition? Yes No
If yes, which medication: __________________________________________________Dose:
What else have you tried that hasnt worked?
Aggravating factors:
Condition 3:
On a scale of 1-10 (10 being severe), how bad is the problem? ____/10
When did it start? _________________________ How?
Is it getting better getting worse staying the same?
How would you describe the problem?
Are you taking medication for this condition? Yes No
If yes, which medication: __________________________________________________Dose:
What else have you tried that hasnt worked?
Aggravating factors:
Work and physical stress
Prolonged sitting Prolonged standing Computer/desk work
Heavy lifting Repetitive motions Studying
Broken Bones/Stitches explain related trauma
Surgery when and for what?
206B Queen Street South
Mississauga, Ontario L5M 1L3
905.826.0900
Dr. Morgan Sinclair
Dr. Casey Sinclair
Dr. Vince Sinclair
Office use only:
Drs Report Date: ________________ 1
st
Adjustment Date: ___________ Dr.
_________________
Lateral Cervical________ Lateral Lumbar __________ scan
AP Lumbar ________ APOM Thoracic ______________ Fee: $_________________