Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.com

Welcome to Peterborough Maximized Living! Please note that this intake form may be completed in advance. If you have completed all information prior to visiting our office, please advise our staff by phone or email as time is set aside when you arrive to complete this information. We will adjust your apointment time slightly as a result. 

Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
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Who Carries this Policy?
Insured's:
Name
Birth Date
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Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
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Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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?
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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?
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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:
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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

Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.com
Personal Illness History
Surgery/Trauma History
Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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

Peterborough Maximized Living Chiropractic Centre
354 Charlotte Street
PETERBOROUGH, ON K9J 2V9
(705) 741-4404
appointments@ptbomaxlivingchiro.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.

Informed Consent to Chiropractic Adjustments and Care:

Physicians, Chiropractors, Osteopaths and Physiotherapists are require to advise patients of benefits and risks including sprain/strain, rib fracture, disc herniation and with neck problems of the following: There have been very rare incidents of injury to the vertebral artery during the course of treatment This has caused strokes or stroke like occurrences, which are usually of a temporary nature. The chances of this happening are less than one in ten million. Tests, with or without x-rays have been performed on you to minimize these risks to yourself. Chiropractic is considered to be one of the safest and most effective forms of therapy form neck conditions. If you have any questions about this, please ask your chiropractor.

I consent to a chiropractic examination.

* Please read and agree to the terms
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Today's Date: 20 Mar 2019