Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com

Welcome to our online Patient Application Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories sign the consent (you can use your mouse or touch screen) and then click the [Submit] button on the last page on the bottom right.

 

Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
First Name
Last Name
Address
City
Postal
Home Phone
Cell Phone
Other Phone
Email
Gender
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
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Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

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Who Carries this Policy?
Insured's:
Name
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Patient Address
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Who Carries this Policy?
Insured's:
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Emp. Phone
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Personal Illness History
Surgery/Trauma History
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

I have completed my health questionnaire to the best of my knowledge and ability.  I understand that completing this application is part the beginning of my journey to better health.  I understand that my first visit will require 30 to 45 minutes and will consist of a review of my health history I have provided, a consultation, a complete chiropractic neurological examination, including: posture analysis, ranges of motion, palpation, Insight Millennium scans (surface electromyography, inferred thermography),to determine the current level of function of my nervous system, and any necessary x-rays will be requested (to rule out pathology, to determine the current structure of my spine and if there is any degeneration).  X-rays will be taken at a convenient off-site location and with current Alberta health care, are at no cost. I understand that all the information gathered by Atlas Family Chiropractic is strictly confidential.  Personal information will not be released to any other party without the appropriate authorization from you.  My history and evaluation will help determine if there is any damage in my spine, if there is any nerve interference and if neurological corrective chiropractic care will benefit my current health condition and/or to my overall health and wellness.  

 

 

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Today's Date: 23 Sep 2018