ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca

Welcome to

ADIO Chiropractic!

 

Please complete the following thoroughly and accurately as this information will help Dr. Danny better understand your concerns and history. 

 

Clicking on certain buttons reveals a space for you to add brief comments. Clicking on the "Submit" button on the final page will send this to our secure server. You do not need to email this form to us.

 

 

We look forward meeting you and seeing what we can do to help!

 

ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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?
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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:

ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.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
ADIO Chiropractic
607-200 Southridge Drive
Okotoks, AB T1S 0B2
(403) 995-0855
maxlife@shaw.ca
Please read the following carefully before signing.

As a potential new patient, we feel it is important that you understand our office policies regarding,    how patients of this practice are cared for, and the various methods we offer to facilitate payment  for that care. Please read each policy carefully so there is no misunderstanding as to what you can expect as a patient of this practice, and what we expect in return. Once you have read Our Office Policies’, if you have any questions or any of these policies are unclear to you, and you would like further explanation before submitting your Application for Treatment, please let our reception know and a member of our staff will be happy to discuss them with you further. We believe it is in everyone’s best interests to provide potential new patients as much information as possible about how the doctors at this office practice chiropractic so that an informed decision can be made as to whether they wish to become a patient.

  Over time, individuals who are accepted, as patients at this office, gain a greater understanding as to the purpose of chiropractic. Since the majority of patient care occurs in an open bay area, patients have a unique opportunity to observe firsthand the positive results that are achieved and the benefits derived from being under chiropractic care. This knowledge and awareness reaps a positive environment that promotes healing and encourages families to maintain good health. We want your experience with us to be an exceptional one, so help us to help you and together we can make affirmative changes in your life and the lives of those you care about.

  PATIENT PRIVACY – Since the majority of patient care takes place in an open bay area it is important to understand that any conversations you have with the doctor can be overheard by other patients. In order to maintain patient privacy it is the policy of this practice to refrain from discussing any confidential matters with patients during treating hours while patients are being adjusted. If you have a confidential matter you wish to discuss please let us know and we will schedule time for you to speak to the doctor in a private consultation room. These consultations must be scheduled in advance.

  YOUR CARE - When a patient seeks chiropractic health care and we agree to provide that care, it is essential for the patient and the doctor to be working toward the same objective. Chiropractic care at ADIO Chiropractic is rendered primarily to minimize and reduce subluxations, which are a major interference to the expression of the body’s innate wisdom. The doctors use a myriad of techniques to accomplish this goal, including but not limited to manual chiropractic adjustments, Thompson drop technique, CLEAR institute adjusting, Impulse Instrument adjusting. It is important that you understand both the objective and the method(s) so there is no confusion or disappointment. Tremendous progress has been made in the rehabilitating and correction of spinal problems. Where in the past, chronic spinal structural problems could not be reversed or corrected, today they can. Your doctor will outline a course of treatment that will take you beyond simple pain relief, through two distinct phases of care to make a structural correction to your spine that will enable your central nervous system to function optimally, thereby improving you overall health.

  FIRST THINGS FIRST- Prior to receiving chiropractic care at this office, a health history and examination will be completed. Imaging studies as well as any other necessary diagnostics may also be ordered, to confirm the true nature of your condition and exact location of subluxations. The results of these procedures will aid in assessing your presenting problem, your overall health and, in particular, the condition of your spine. They will also assist the doctor in determining the type and amount of care you will need. All relevant findings will be reported to you along with care plan recommendations so that you can make the best possible decision regarding your health care needs. Our gold standard for care is to ensure the reduction of subluxation while teaching patients what they need to do in addition to being adjusted to maintain their health for a lifetime.

  PATIENT’S REPORT OF FINDINGS – To enhance your understanding of the chiropractic approach that will be used to manage your health, immediately following your first adjustment, you will be scheduled for a ‘Doctors Report of Findings’. The information you receive at this appointment will be both informative and clinically relevant to your case, therefore attendance is required for individuals who wished to become new patient of this practice. Because the results of your x-rays and all examinations as well as the doctors’ recommendations for care, will be discussed at that time, we strongly urge new patients to invite their spouse or significant other to attend. We know from experience that when a patient’s family understands the goals and objects of chiropractic care and how restoring and maintaining good health can affect their lives as well, they become infinitely supportive and helpful in making important decisions concerning treatment options.

 

I hereby acknowledge having read the ‘Our Office Policies’ document. I am able to print or save this document if needed for future reference. I further acknowledge that any concerns regarding these ‘Policies‘ as well as all my questions have been answered by a qualified member of the staff to my complete satisfaction. My signature below recognized my understanding of this ‘Notice‘.

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 17 Oct 2017