This Health History Form will assist me in providing you with a safe and an effective treatment. You must notify us of any changes in your health status. Please feel free to ask questions regarding the health history form. Please note that all information provided is strictly confidential and will not be released to anyone without your prior written permission.

Name

Date of Birth (M/D/YY)

Address

City

Province/Territory Province/Territory *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonUnited StatesInternational

Postal Code

Email Address

Occupation

Cell Number

Tel Number 2

Emergency Contact Name

Emergency Contact Phone

Reason for Seeking Treatment Today? (Specify when and how you were injured)

Main Area(S) you wish me to focus on today (Specify)

Current Medications and Conditions they Treat

Family Doctor

How Did You Hear About Us? (Indicate Name)

PLEASE MARK ANY OF THE CONDITIONS LISTED BELOW, THAT APPLY TO YOU: PLEASE MARK ANY OF THE CONDITIONS LISTED BELOW, THAT APPLY TO YOU:

CARDIO VASCULAR CARDIO VASCULAR Heart Attach Stroke Pacemaker Aneurism High BP Low BP Heart Disease Varicose Veins Atherosclerosis Bleed Disorder DVT (Clots) Heaviness in Limbs

INFECTIOUS CONDITIONS INFECTIOUS CONDITIONS Hepatitis Herpes Warts Foot fungus Poison Ivy Poison Oak Poison Parsnip Poison Sumac STI (STD) HPV HIV

NERVOUS SYSTEM CONDITIONS NERVOUS SYSTEM CONDITIONS Seizures Epilepsy Hearing Loss Vision Loss Shakiness in Limbs Headaches Pins/Needles

SKIN CONDITIONS SKIN CONDITIONS Allergy to Heat Allergy to Cold Allergy to oils Eczema Psoriasis Acne Cysts Current Rashes/Cuts/Abrasions Current Open Sores/Wounds Swelling Anywhere Hives Any Other Allergies? Specify in comments below.

*Specify Skin Condition/Allergy

RESPIRATORY SYSTEM CONDITIONS RESPIRATORY SYSTEM CONDITIONS Chronic Cough Emphysema Asthma Chronic Bronchitis Shortness of Breath Infectious Respiratory Conditions (sore/strep throat, etc.)

DIGESTIVE SYSTEM CONDITIONS DIGESTIVE SYSTEM CONDITIONS Eating Disorders IBS Abnormal Bowel Movements

OSTEOLOGY SYSTEM CONDITIONS (BONES) OSTEOLOGY SYSTEM CONDITIONS (BONES) Osteoporosis Osteoarthritis Rheumatoid Arthritis Disc Disease Surgery (Pins/Screws /Plates/Wires)

MISCELLANEOUS CONDITIONS MISCELLANEOUS CONDITIONS Pregnant Diabetes Hernia Cancer Hemophilia Mental Illness