New Patient Registration

Date:

Thank you for choosing Gilmour Chiropractic and Wellness. Your health history is important to us. Please read through this entire document and provide as much information as possible.

Are you the patient or are you completing this form for a patient?

□ I am the patient □ I am completing this for the patient Relation to patient:

Personal Information

Last Name:

First Name: Middle Initial(s):

Date of Birth: Gender:

Address 1:

Address 2:

City: Province: Postal Code:

Home Phone: Mobile Phone:

Email Address:

How did you hear about us?

Who is your family doctor?

Chief Complaint

Reason for today’s visit:

Describe your current symptoms:

Have you felt these symptoms before?

If yes, is it better or worse than before?

When did your symptoms begin?

Was your pain caused by a specific incident?

What makes it better?

What makes it worse?

Does physical activity make it worse?

Does your pain level change over the course of the day?

If yes, please describe:

Has this complaint been treated by any other medical professionals?

If yes, please describe:

Have you ever been treated by a chiropractor before?

If yes, please provide their information

Is there any further information you would like to provide regarding your current complaint?

Does the pain interrupt your sleep?

Current Health History

Please list current medications (prescription, over-the-counter, supplements)

1. 2. 3. 4. 5.

Privacy Verification

□ I understand that I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties

Permission to Contact

□ I grant permission to be contacted to confirm or reschedule an appointment, or to provide health information as an extension of my care in this office

Payment Verification

□ I understand that any insurance that I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services that I receive.

General Verification

□ To the best of my ability, the information I have supplied is complete and accurate.

Signature of Patient: _____________________________________

Signature of Guardian (if necessary):_________________________