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
Gender
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.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
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.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
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.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:

Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.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
Century Chiropractic Wellness Centre
4624 16th Ave, NW
CALGARY, AB T3B-0M8
403-289-8285
info@centurywellness.ca
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
Relationship to patient
Signature
Today's Date: 14 Dec 2019