Get Patient/client History Form

Completing the Patient/Client History Form online is an essential step in receiving appropriate care. This guide will assist you in accurately filling out each section to ensure that your health information is documented correctly.

Follow the steps to properly complete your Patient/Client History Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the first section. Provide your full name, phone numbers (home and work/cell), address, date of birth, email address (for clinic use only), employer details, and position. Additionally, fill in the information for your emergency contact and indicate how you were referred to the clinic.
3. In the Medical History section, specify your physician's name and address, along with the date of your last physical and their phone number. Detail any treatments you have received from chiropractors, physiotherapists, medical doctors, naturopaths, and other specialists by entering their names, dates of treatment, and reasons for treatment. Address questions regarding any previous surgeries, motor vehicle accidents, serious injuries, or headaches, and elaborate as necessary.
4. Move to the Reason for Visit section and describe your current condition or reason for visiting. Clearly articulate the type of pain you are experiencing and rate its intensity on a scale of 1 to 10. Detail the duration of this pain, the initial onset, probable cause, and your expectations for today's treatment.
5. In the Current Medication section, list any prescription or non-prescription medications, natural remedies, or supplements you are currently taking, along with the reasons for taking them.
6. Fill out the Family History section by indicating whether you or your immediate family members have any specified health conditions, as well as their current health status.
7. For the Psycho-social History section, answer questions about smoking and drinking habits, your daily water intake, exercise frequency, and types of exercise. Indicate your hobbies or recreational activities and assess your work and home stress levels.
8. Finally, ensure that you review all provided information for accuracy. By signing the form, you acknowledge that the information is true and accurate to the best of your knowledge. Include the date of signing.
9. Upon completing the form, you can save your changes, download, print, or share the document as needed.

Start filling out your Patient/Client History Form online today for timely medical attention.