The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.ca

Why This Form Is Important: 

In this office, our focus is on helping people to function optimally so that they are stronger, healthier and better able to adapt to the stresses of everyday life.  This form gives us a better understanding of the physical, chemical and emotional stresses that can gradually accumulate over time to produce health problems.  Please complete this form as thoroughly as possible and our team will review it with you.

The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.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?
The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.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
The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.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
The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.ca
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.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:

The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.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
The Wellness Studio
1603 20th Ave NW
Calgary, AB T2M 1G9
(403) 228-5433
info@thewellnessstudio.ca
Please read the following carefully before signing.

I verify that the supplied information is true to the best of my knowledge

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 20 Jul 2019