24 Charing Cross Street, Brantford ON, N3R 2H2

+1 (519) 752-8100

Office Hours

Monday
7.30am – 11am
2pm – 6:00pm
Tuesday
7:30am – 10:45am
2pm – 5:45pm
Wednesday
2pm – 6pm
Thursday
7:30am – 11am
2pm – 6pm
519-752-8100
View Hours

Family Care Chiropractic - New Patient

Thank you for your interest in becoming a new patient! Please fill out the form below.




























  • Please list any surgeries you have had.



  • Please check the box
    if you had other surgeries.


  • List any Prescription or Non-Prescription Medication you are presently on.
  • Condition #1

  • Condition #2

  • Condition #3

  • Please check the box if you take other medications, and bring your complete
    prescription list with you.


  • Doctors of Chiropractic are the ONLY health care professionals educated and trained to detect and help correct spinal misalignments that put pressure on nerves, called vertebral subluxations. These subluxations are caused by any stress to which your body cannot adapt. Since a vertebral subluxation interferes with your body's overall performance and health, it may be the underlying cause of any or all of the following symptoms.

    PLEASE CHECK THE SYMPTOMS YOU HAVE EXPERIENCED RECENTLY
  • MUSCULO-SKELETAL
    Low Back Pain
    Pain between Shoulders
    Neck Pain
    Arm/Hand Pain
    Leg/Foot Pain
    Walking Problems
    Difficulty Chewing
    Jaw Clicking (TMJ)
    Shoulder Problems
    Elbow Problems
    Wrist Problems
    Knee Problems


  • GASTRO-INTESTINAL
    Poor/Excessive Appetite
    Excessive Thirst
    Frequent Nausea
    Vomiting
    Diarrhea
    Constipation
    Hemorrhoids
    Liver Problems
    Gall Bladder Problems
    Weight Problems
    Abdominal Cramps


  • EYES/EARS/NOSE THROAT
    Vision Problems
    Dental Problems
    Sore Throat
    Ear Aches
    Recurring Ear Infection
    Hearing Difficulty
    Ringing/Buzzing Ears
    Stuffy Nose
    Sinus Problems


  • NERVOUS SYSTEM
    Numbness
    Paralysis
    Dizziness
    Forgetfulness
    Cold/Tingling Extremities
    Stress
    Epilepsy
    Convulsions


  • GENITO-URINARY
    Bladder Trouble
    Painful/Excessive Urination
    Discolored Urine
    Difficulty Urinating


  • STRESS
    Depression
    Anxiety
    Chronic Fatigue
    Recent Death in Family


  • GENERAL
    Fatigue
    Allergies
    Difficulty Sleeping
    Headaches
    Migraines
    Gas / Bloating after meals
    Heartburn
    Black/Bloody Stool
    Colitis


  • CARDIO-VASCULAR RESPIRATORY
    Shortness of Breath
    Asthma
    Blood Pressure Problems
    Irregular Heartbeat
    Heart Problems
    Lung Problems/Congestion
    Varicose Veins
    Ankle Swelling
    Stroke
    Fainting


  • MALES ONLY
    Chest Pain/Lumps
    Prostate Sexual Dysfunction


  • FEMALES ONLY
    Are you Pregnant?
    Menstrual Cramping
    Menstrual Irregularity
    Vaginal Pain/Infection
    Breast Pain/Lumps



  • If you are experiencing any other symptom not listed above, please list:

    What do you wish to do again or more of once you return to better health?

      Today's Date: Wednesday, December 13, 2017

      This form will be printed at the Dr.'s Office where you will be required to sign it.