Comprehensive Health Profile

Last Name:______First Name______Today's date______Address:______City______Prov:______Postal code______Home phone:______Work phone:______ext:______E-mail______Date of birth:______Occupation:______Status:______Children:______How did you discover our office, and the professional services we offer?______Please complete this general health history survey, as it will provide your doctor with important informations to better understand your history, your present and longer term needs, and any compromise to your wellness or health related quality of life that you may now be experiencing.

Part I : Your Health Concerns or Symptoms and How They Affect Your Life 1. Do you have any current health concerns? If so, please describe. ______2. When did this situation or concern begin?______3. Have you done anything about this situation or concern or gotten any advice or treatement for it? Yes _No_ If yes, what were you told?______4. What was done?______5. Did it seem to work?______6. What was different about you after treatement?______7. What was different about your condition or symptom after treatement?______9. Please grade the level to which these health concerns affect these aspects of your functionning / quality of life. 0-No effects 1-slights effects 2-Moderate effects 3-Drastic effects Effects on work 0 1 2 3 Effects on recreation /play 0 1 2 3 Effects on rest /sleep 0 1 2 3 Effects on social life 0 1 2 3 Effects on walking 0 1 2 3 Effects on sitting 0 1 2 3 Effects on exercice 0 1 2 3 Effects eating 0 1 2 3 Effects on love life 0 1 2 3 Concern about particular symptom condition 0 1 2 3 Concern about health 0 1 2 3 Comments:______10. Has any other family member had the same or similar concerns? Yes___No___ What did he /she do about them?______11. Did it seem to work?______12. How aware of this are you during the day? 0 1 2 3 at night? 0 1 2 3 13. Is there any time, or activity you can be involved with when you totally or almost forget about this condition, symptom or concern about this?______

La Source de Vitalité 435 Bd La Vérendrye Est Gatineau, Qc J8R 2W8 14. Is there any time of day or activity which makes you aware of it?______15. Why do you think this has happened or continues to happen to you?______16. Do you think this is the sole cause? Yes___ No___ 17. If no, what else is involved?______18. If this condition or symptom were to go away tomorrow, what would be different about your life?______19. What are you doing in your life that is different than what you would be doing if you did not have this condition /symptom?______20. Since this happened: a) Have you any changed habits?______21. Which best describes your current feeling about yourself and your situation? a) I feel helpless like little or nothing works. b) This is terrible, really bad, I am scared, and hope you can fix it for me. c) I feel stuck, and can't help myself right now. d) I deserve more than what I have been experiencing, and would like you to assist me in my healing. e) Anything else?______22. Please grade the following on a scale of 0 to 3, 0-not at all, 1-slight, 2-moderate, 3-extreme, Currently, how inconvenient is your situation, condition or symptom? 0 1 2 3 a) How inconvenient was it in the past? 0 1 2 3

Part II: Health /Trauma / Medical / Chiropratic and Healing Hystory:

1. Have you ever injured your spine (neck, back, hips )? a) Date of most significant injury:______b) What happened?______c) Date of most recent injury:______d) What happened?______2. Have you been injured at work or in a car accident ? Yes____No____ Please explain:______3. Please list medications (prescription or non prescription ) you have taken within the past 60 days:______4. In the past, have you taken other medications for a period of more than 3 months ? Yes____No____ a) What did you take ?______

La Source de Vitalité 435 Bd La Vérendrye Est Gatineau, Qc J8R 2W8 b) What was the reason for taking this medication? ______5. How many cigarettes do you smoke per days?______None_____

6. Have you had any spinal X-rays, Cat scans or MRI imaging of your spine or head (neck, back or hip) ? When?______7. What were you told about them?______8. Where are these films now?______9. Have you had any surgeries? Please explain:______10. Have you broken any bones, or significantly sprained part of your body? Yes____No____ Please explain:______11. Please list any herbs, nutritional supplements or natural home remedies you take regularly.______12. Have you consulted a physician, or any other health care provider in the past three months? ______13. Has you r spine ever been professionally adjusted? Yes____No____ a) By whom and when?______b) Why did you go?______c) Are you still going? Yes____No____ d) What did he/she do for you?______e) Were you pleased? Yes____No____ f) Does your family receive chiropratic care? Yes____No____ 14. Do you consult with a physician for other than routine evaluations? Yes____No____ 15. What is/was the reason for the visit(s) ?______16. When was your last visit?______17. What was done or suggested?______18. Have you had experience with the following health, treatment or healing modalities? If so, please describe when you went, for how long you went, and what the results were: Massage /Bodywork______Emotional Therapy / Psychotherapy______Osteopathy______Physiotherapy / Occupational Therapy______Music / Danse / Sound / Light / Aroma therapy______Homeopathy / Herbalist______Ayurvedic Medecine______Oriental Medecine / Acupuncture______Nutritional Conseling / Therapy______

La Source de Vitalité 435 Bd La Vérendrye Est Gatineau, Qc J8R 2W8 Oxygen Therapy / Chelation Therapy______Rebirthing / Breathwork______Yoga / Movement / Dance / Tai chi / Chi Gong______Somato Respiratory Integration______Other:______19. Do you have an exercice, meditation, prayer, nutritional or dietary program? Please describe______20. When stressed, how do you "center your self" or "regroup" ? ______

Part 111 Stress Survey:

With each of the following spinal stress situations, please check either "P" for Past or "C" for Current. Mild Moderate Extreme P C P C P C Childhood Stress       School Stress       Play, or recreational       Family stress       Personnal relationships       Stress Of being sick       Work related stress       Stress of commuting       Loss of loved one       Change in lifestyle       Change in vocation       Abuse      

Part IV: Your Specific N eeds and Hopes For Help in ThisOffice? Use this scale for question 1: a) very important to me b) important to me c) not so important to me d) does not apply

1. Which of the following five choices is currently of most interest to you? In a published study of over 2,800 patients in Network Care, conducted within the Medical College at the University of California-Irvine, patients reported an overall improvement in all of the categories of health and wellness listed below. How do you hope to benefit from care in the office? a) ____Improvement of my physical symptoms

La Source de Vitalité 435 Bd La Vérendrye Est Gatineau, Qc J8R 2W8 b) ____Improvement of emotional / mental symptoms c) ____Improvement of my ability to react or respond to stress d) ____Improvement in enjoyment of life and the ability to make conductive choices e) ____Overall improved quality of life

2. Is there some aspect of your life that very much pleases you, brings you joy, or helps you to feel better about yourself? ______

3. Are there any particular factors or elements about your life, experiences, family, work, recreation, past injuries, genetics, dietary programs, exercises, outlook, etc that you feel impair your opportunity for full glowing health?______4. Are there any particular factors or elements about your life, experiences, family, work, recreation, past injuries, genetics, dietary programs, exercises, outlook, etc. that you feel give you an edge, or adds to your health? ______

Thank you for choosing the "Source de Vitalité" We are looking forward to help you to be successful in your ability to develop a healthy spine and nervous system. We are excited about the possibility of assisting you as you continue on your journey towards greater health and wellness.

Chiropractic is a lifestyle and a family affair. We give you the opportunity to have members of your immediate family Examined without any additional charge as long as these exams are done within two weeks.

We strongly encourage parents to have their children examined.

Signature______Date______

La Source de Vitalité 435 Bd La Vérendrye Est Gatineau, Qc J8R 2W8