Home Address:
	Street Address	City	Province

Postal Code:

Home Phone:

Work:

Cell:

Date of Birth:		Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec		Present Age:
	Year	Month	Day

Place of Birth:

Marital Status:

Single

Married

Divorced

Widowed

Occupation:

If a Minor, Parents' Names:

PHN (Care Card Number)

Family Doctor:

Please List your Present Major Health Concerns (starting with the most troublesome to you):

	Since
1.
2.
3.
4.
5.
6.

Date of Last Physical Examination (and by whom):

Any Abnormal Findings?

Please List Recent X-Rays or Other Investigations including Conventional and Non-Conventional (include: when, which tests, and results)

Other Health Practitioners you are Currently seeing (or have recently seen):
Include: Family Doctor, specialists, physiotherapists, naturpoaths, chiropractors, massage therapists, acupuncturists, herbalists, etc.

1.	2.
3.	4.
5.	6.

ALL Current Medications (Prescription, Non-Prescription, Herbs, Vitamins, etc.) Please put each one on a new line.

Personal History	Family History
Smoker	HayFever/Asthma/Eczema?
Alcohol? Type:  Amount per Week:	Heart Disease/Strokes?
Recreational Drugs?	Diabetes? Cancer? Depression
Kown Allergies?	Other Mental Disease?

Additional Medical History (Please Provide in chronological order)
Include any medical treatments and the results of these (also any non-conventional treatments such as infrared sauna, laser therapy, cosmetic treatments, electromagnetic treatment devices, etc.) and all surgical operations.