Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca

 

Welcome to the family health and wellness centre.  Our focus is to provide the highest standard of treatment, care and ethics to best suit the needs of our family community.

 

Please take a few minutes to fill out the patient form before your first appointment. Once finished, press submit and the form will automatically be sent to our clinic before your arrival.

 

If you have any question regarding this, please feel free to contact us at 403-289-8285 or email to us at centurychiro@shaw.ca.

 

Once again, welcome and thank you for choosing Century Chiropractic Wellness Centre.

 

 

Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Postal
Prov
Employer
Emp. Phone
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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?
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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?
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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:
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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

Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
Sensory
Integumentary
Endocrine
Genitourinary
General
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
Personal Illness History
Surgery/Trauma History
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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

Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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.

Consent to the Use and Disclosure of Health Information

 

I understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment.  I understand that this information serves as a basis for planning my care and treatment; a means of communication among other health professionals who may contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; and a means by which a third-party payer (MVA, WCB) can verify that services billed were actually provided.  I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the practice is not required to agree to the restrictions requested.

 

I hereby agree that the information that I am providing is accurate to the best of my knowledge and I will not hold Century Chiropractic Wellness Centre, its staff, doctor(s), or other practitioner(s) responsible for any information that I have not provided to them during the initial involvement and/or treatment provided thereafter at Century Chiropractic Wellness Centre.

 

Thank you for taking the time to fill out our forms.  Your information is private and confidential.  It will go a long way to helping us to help you to achieve your health goals.  We look forward to meeting you!

 

To the best of your knowledge, please ensure that the information provided is accurate (click "Agree" below)

* Please read and agree to the terms
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Today's Date: 14 Dec 2019