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 (use you mouse or touch screen) then click the [Submit] button on the last page at the bottom.

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
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
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
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
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
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
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:

Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
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
Atlas Family Chiropractic
5113, 403 Mackenzie Way SW
AIRDRIE, AB T4B 3V7
(403) 945-9450
drglen@atlaschiroairdrie.com
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 family’s journey to better health.  I understand that my first visit will require 30 to 45 minutes and will consist of a review of my child’s 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 child’s nervous system, and children are not typically sent for x-rays unless there is clinical evidence of an underlying pathology.  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.  I understand that this process is to determine if neurological corrective chiropractic care will benefit my child’s current health condition and contribute to my families overall health and wellness.  

 

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 21 Aug 2018