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Dr. Ali Amiri

Car Accident Care

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Home

About
- Meet The Team
- Events
- Past Events
- Videos
- Blog

More
- Dr. Ali Amiri
- Car Accident Care
- Chiropractic Care
- New Patients
- Payment Options
- FAQs
- Reviews
- Contact

Patient Health History Form

How did you hear about our office?

First Name*

Last Name*

Preferred First Name

Street Address*

City

Province

Postal Code*

Cell Phone Number*

Gender

Male

Female

Other

Birthday: M-D-Y*

Age:

Marital Status

Married

Single

Other

Spouse Name

Number of Children

Family Doctor's Name

Occupation

Employer

Have you been to a Chiropractor before?

Name of previous Chiropractor

How long were you under care?

ICBC - CAR ACCIDENTS

Do you have an open claim with ICBC for a car accident?

Yes

If yes, what is the ICBC claim number?

What is the accident date?

Are you currently off work due to the accident?

Have you been absent to any of the following due to the accident?

Work

Training

School

Are you employed/engaged in any of the following?

Health Conditions

Please check any of the following conditions currently or recently experienced:

Please list any Medications you are currently taking

List all surgeries you have had in your life

List all broken bones you have had in your life

Reason for this Visit

The main reason for your visit*

Health Conditions:

When did this problem begin?

How did this problem begin?

On a scale of 0 to 10, 10 being the worst pain, rate your pain level on average

Overall frequency of complaint (Please check only one)

Constant - 100% of the time

Frequent - 75%

Intermittent - 50%

Occasional - 25%

Is this condition:

Getting better

Getting worse

Staying the same

What aggravates the problem?

What relieves the problem?

Place an X on the image below, where you feel pain, numbness or tingling:

Please fill in area

What activities can you NOT DO because of this problem, that you LOOK FORWARD TO DOING when these problems are resolved?

OPT-IN CONSENT FOR EMAIL AND TEXT

I agree to receive emails and/or text messages from Coquitlam Family Chiropractic for my appointments, statements, x-rays, office closures, reviews and special events. I understand that I can opt-out anytime.

Patient's Signature

Date

Thank you for taking the time to fill out this form.

15+
Years experience

15,000+
Patients served

150,000+
Treatments delivered

Where we are
located :

Coquitlam Family Chiropractic

Address: 210 - 2885 Barnet Hwy,
Coquitlam, BC V3B 1C1, Canada

Clinic Hours

Monday

- - -

4:00 - 7:00 PM

Tuesday

9:00 - 11:00 AM

4:00 - 7:00 PM

Thursday

9:00 - 11:00 AM

4:00 - 7:00 PM

Friday

- - -

4:00 - 7:00 PM

Phone: (604) 941-0003

Email: info@coquitlamfamilychiropractic.com

Website: https://www.coquitlamfamilychiropractic.com

Address:
210 - 2885 Barnet Hwy,
Coquitlam, BC V3B 1C1, Canada