Welcome to Revive Upper Cervical Chiropractic! We are thrilled to help you in the process of getting to the root cause of your problem and getting your life back. Our entire team is looking forward to meeting you and helping you in this endeavour. Please complete the following forms with as much detail as possible, and we will review them in advance of your appointment to make the best use of your time when you come in to see us. If you have any questions prior to your appointment please do not hesitate to contact us, otherwise we look forward to meeting with you soon.
How Can We Help?
Activities of Daily Living
*Examples can include but are not limited to: sitting, standing, or walking for a period of time or distance, bending, driving a car, looking over shoulder, household chores, career or work, recreational activities, sleep, exercise, etc.
- Single
- Married
- Divorced
- Widowed
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Confidential Family Information
*please select all that apply
- Nervousness
- Irritability
- Fatigue
- Panic Attacks
- Issues Sleeping
- Feeling Run-Down
- Loss of Coordination
- Loss of Memory
- Muscle Weakness
- Inability to Form Words
- Burning Sensations
- Itchy Skin - Eczema
- Rough, Scaly Skin
- Dry Skin
- Oily Skin
- Yellow Skin
- Bruise Easily
- Baldness
- Paper Thin Nails
- Nail Biting
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Shortness of Breath
- Dry Cough
- Wheezing
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Poor Appetite
- Constant Nibbling
- Nausea and Vomiting
- Abdominal Pain
- Diarrhea
- Constipation
- Hemorrhoids
- Acid Reflux
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Frequent and Severe Headaches
- Head Feels Heavy
- Vertigo
- Dizziness
- Light Headedness
- Loss of Balance
- Pressure Over Eyes
- Frequent Colds
- Sinusitis
- Allergies
- Blurred Vision
- Double Vision
- Eye Fatigue
- Excessive Tearing
- Lack of Tearing
- Light Sensitivity
- Excessive Itching
- Pain in Eyeball
- Pain in Throat
- Dentures
- Difficulty Swallowing
- Loss of Hearing
- Pain in Ears
- Discharge from Ears
- Ringing in Ears
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Pain in Neck
- Pain with Movement
- Swelling and Stiffness
- Pinched Nerve in Neck
- Muscle Spasms in Neck
- Grinding Sounds in Neck
- Popping Sounds in Neck
- Limited Neck Movement
- Pain in Shoulders
- Pain Across Shoulders
- Muscle Spasms
- Can't Raise Arm above Head
- Can't Raise Arm above Shoulder
- Pain between Shoulder Blades
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Pain in Upper Arm
- Pain in Forearm
- Swollen Fingers
- Cold Hands
- Loss of Grip Strength
- Pain in Hands and Fingers
- Pins and Needles in Arms
- Pins and Needles in Fingers
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Low Back Pain
- Sharp Stabbing Pain
- Dull Ache
- Pain from Front to Back
- Pain over Kidney Area
- Muscle Spasms
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Mid Back Pain
- Sharp Stabbing Pain
- Dull Ache
- Pain from Front to Back
- Pain over Kidney Area
- Muscle Spasms
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Pain in Hip
- Pain down Leg
- Pain in Buttocks
- Knee Pain
- Leg Cramps
- Pins and Needles in Legs
- Numbness in Legs and Toes
- Cold Feet
- Swollen Legs or Ankles
- Swollen Feet
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Varicose Veins
- Pounding Heart Beat
- Chest Pain
- Rapid Heart Beat
- Heart Attack
- High Blood Pressure
- Blood Vessel Disease
- Irregular Heart Beat
- Blue or Purple Skin
- General Swelling
- Swelling in Face
- Blue or Purple Nail Beds
- Fainting
- Stroke
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Urination is Frequent
- Urination is Not Sufficient
- The amount is: Moderate-High
- The amount is: Low-Moderate
- Intense Desire to Urinate
- Difficulty Urinating
- Lack of Control
- Pain with Urination
- Bloody or Cloudy Urine
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Painful Periods
- Spotting
- Premenstrual Symptoms
- Irregular Periods
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Anxiety
- Arthritis
- Asthma
- Allergies/Sinusitis
- Back Pain
- Cancer
- Carpal Tunnel
- Constipation
- Depression
- Ear Infections
- Epilepsy
- Fibromyalgia
- Headaches
- Heart Trouble
- Insomnia
- Kidney Trouble
- Liver Trouble
- Meniere's Disease
- Migraines
- Multiple Sclerosis
- Muscle Problems
- Nervousness
- Neuritis
- Parkinson's Disease
- Pinched Nerves
- Sciatica
- Scoliosis
- Stomach Trouble
- TMJ Problems
- Vertigo/Dizziness
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Anxiety
- Arthritis
- Asthma
- Allergies/Sinusitis
- Back Pain
- Cancer
- Carpal Tunnel
- Constipation
- Depression
- Ear Infections
- Epilepsy
- Fibromyalgia
- Headaches
- Heart Trouble
- Insomnia
- Kidney Trouble
- Liver Trouble
- Meniere's Disease
- Migraines
- Multiple Sclerosis
- Muscle Problems
- Nervousness
- Neuritis
- Parkinson's Disease
- Pinched Nerves
- Sciatica
- Scoliosis
- Stomach Trouble
- TMJ Problems
- Vertigo/Dizziness
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Anxiety
- Arthritis
- Asthma
- Allergies/Sinusitis
- Back Pain
- Cancer
- Carpal Tunnel
- Constipation
- Depression
- Ear Infections
- Epilepsy
- Fibromyalgia
- Headaches
- Heart Trouble
- Insomnia
- Kidney Trouble
- Liver Trouble
- Meniere's Disease
- Migraines
- Multiple Sclerosis
- Muscle Problems
- Nervousness
- Neuritis
- Parkinson's Disease
- Pinched Nerves
- Sciatica
- Scoliosis
- Stomach Trouble
- TMJ Problems
- Vertigo/Dizziness
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Anxiety
- Arthritis
- Asthma
- Allergies/Sinusitis
- Back Pain
- Cancer
- Carpal Tunnel
- Constipation
- Depression
- Ear Infections
- Epilepsy
- Fibromyalgia
- Headaches
- Heart Trouble
- Insomnia
- Kidney Trouble
- Liver Trouble
- Meniere's Disease
- Migraines
- Multiple Sclerosis
- Muscle Problems
- Nervousness
- Neuritis
- Parkinson's Disease
- Pinched Nerves
- Sciatica
- Scoliosis
- Stomach Trouble
- TMJ Problems
- Vertigo/Dizziness
- No elements found. Consider changing the search query.
- List is empty.
*please select all that apply
- Anxiety
- Arthritis
- Asthma
- Allergies/Sinusitis
- Back Pain
- Cancer
- Carpal Tunnel
- Constipation
- Depression
- Ear Infections
- Epilepsy
- Fibromyalgia
- Headaches
- Heart Trouble
- Insomnia
- Kidney Trouble
- Liver Trouble
- Meniere's Disease
- Migraines
- Multiple Sclerosis
- Muscle Problems
- Nervousness
- Neuritis
- Parkinson's Disease
- Pinched Nerves
- Sciatica
- Scoliosis
- Stomach Trouble
- TMJ Problems
- Vertigo/Dizziness
- No elements found. Consider changing the search query.
- List is empty.
*this section will be empty if the patient's age entered above is 18 or older
- Ear Infections
- Asthma
- Allergies
- Colic
- Seizures
- Bed Wetting
- Digestion Issues
- Scoliosis
- ADHA/ADD
- Chronic Colds
- Recurring Fevers
- Growing Pains
- Headaches
- Back Pain
- Neck Pain
- Temper Tantrums
- Anger Issues
- Sleep Issues
- No elements found. Consider changing the search query.
- List is empty.
*this section will be empty if the patient's age entered above is 6 years or older
- Laughs
- Moves / Makes sounds to get your attention
- Looks at self in mirror
- Reacts to strangers
- Varied facial expressions
- Responds to name
- Copies others
- Looks to see how you react in new situations
- Plays next to / with other children
- Follows simple routines when told
- Pretends to be something else during play
- Follows rules
- Takes turns
- No elements found. Consider changing the search query.
- List is empty.
- Reacts to sound
- Makes sounds other than crying
- Blows raspberries
- Used sounds like "Mamamama"
- Waves by
- Points to ask for something or to get help
- Uses 3+ words beside "mama" or "dada"
- Points to body parts when asked to show
- Uses gestures other than waving (ex: blowing kisses, nodding yes or no)
- Uses 2-3 word phrases
- Asks "who, what, where, or why" questions
- Speaks using sentences with 4+ words
- Tells a story they heard or made up with at least 2 events
- No elements found. Consider changing the search query.
- List is empty.
- Watches as you move
- Plays with hands
- Puts things in their mouth to explore
- Reaches to grab a toy of interest
- Looks for objects when dropped out of sight
- Looks for things they see you hide
- Feeds self with fingers
- Tries to use switches, knobs, or buttons on a toy
- Plays with more than one toy at a time
- Shows simple problem solving skills (ex: standing on a stool to reach)
- Identifies at least 1 color
- Copies a circle
- Writes some letters in their name
- Names letters when you point to them
- No elements found. Consider changing the search query.
- List is empty.
- Primitive grasp reflex
- Holds head up
- Pushes up onto elbow/forearm while on tummy
- Rolls from tummy onto back
- Pushes up with straight arms while on tummy
- Crawls
- Sits unsupported
- Pulls up to stand
- Walks holding onto furniture
- Picks things up with thumb and pointer finger
- Takes several steps without help
- Walks unassisted
- Runs
- Walks upstairs without help
- Unbuttons several buttons
- Hops on 1 foot
- No elements found. Consider changing the search query.
- List is empty.
After submitting your forms, you will receive an email requesting your signature, please review the document and sign!