The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca

We believe that you were DESIGNED to be EXTRAORDINARY

At The Healthy Family Chiropractic & Wellness Centre our goal is simple - to offer the best, most thorough, most advanced chiropractic care available. We are proud the be one of the largest chiropractic offices in Ontario and one of the few in the world who specialize in spinal correction.

It is our mission to set people free to live the abundant life.   We engage our people in true health care - a joint journey between doctor and patient with the common goal of experiencing life to the fullest. We share this journey with newborns, children, teenagers, adults and seniors,

A person doesn't necessarily have to be in pain to be a patient at The Healthy Family, just have a desire to live life to its fullest potential. Our brand new state-of-the-art office is equipped with the latest technology, including on-site digital X-ray, Advanced Digital X-ray marking software and digital spinal Electromyography scanner; making examination both efficient and thorough.  

Dr. Posa has vast experience taking care of newborns, pregnant women, young children, adults and seniors.  The office mission is to have a tremendous proactive impact on the health of our community.  We intend on making The Healthy Family a world leader in quality health care.

At your first visit to our office, we will listen to you, discuss your personal health goals, and give you one of the most thorough examinations you've ever received.  Our goal isn't to simply make you feel better, but to eliminate the underlying cause of your health concern. 

After your initial consultation, the doctor will take time to review your case, and invite you back for a special report of findings visit.  By this point, the doctor will have prepared a verbal and written summary of your case; along with detailed recommendations for recovery and maintenance of your health. Let's get started!

The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
First Name
Last Name
Address
City
Postal
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
The Health Family Chiro & Wellness
850 Main St. E Unit 4
Milton, ON L9T 0J4
(905) 864-1516
info@thehealthyfamily.ca
Please read the following carefully before signing.

When a patient seeks chiropractic health care and when a Chiropractor accepts a patient for such care, it is essential that they both are seeking and working for the same goal.

 

Chiropractic has only one goal. It is important that a patient understand this goal and the means that will be used to attain it. In this way there will be no confusion, misunderstanding or disappointment.

 

Patients usually want their conditions, ailments or symptoms treated. This is not the goal of the Chiropractor. The purpose of chiropractic is to restore and maintain the integrity of the spinal cord and its nerve roots in order to achieve optimal health. These vital nerve pathways are housed in and protected by the bones of the spine.

 

Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which caused alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential. 

 

Adjustment: An adjustment is a specific application of forces intended to reduce or correct subluxations, restoring normal nerve function. The goal of chiropractic is to minimize the devastating effects of subluxations, so that every part of the body is working at a maximum efficiency. 

 

Regardlesss of the disease, Dr. Matthew Posa is not offering to heal, treat or cure it. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to reduce or correct vertebral subluxations.

 

 

I understand that The Healthy Family will provide itemized account history to assist me in making collection from my insurance company. I understand and agree that all services rendered are charged directly to me and that I am peronally responsible for payment.

 

There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscles and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures;

 

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurence of stroke. Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occuring in association with upper cervical adjustment is extremely remote;

 

c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused , or may be caused, by spinal adjustments or other chiropractic treatment;

 

I acknowlege I have red this consent and have discussed, or have been offerent the oppertunity to discuss with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment). the treatment options and recommendations for my condition, and the contents of this consent.

 

I concent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments.

 

I intend this consent to apply to my examination and all my present and future chiropractic care.

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 19 May 2019