Initial Consultation Forms

The forms below are for first time patients to Fairway Chiropractic Centre.

Adult Consultation History

Initial Child & Adolescent Questionnaire

Family Health History

Health Questionnaire

These forms are in PDF format. Please click on the approriate form to download a copy to your computer. Print the form out and remember to bring it with you at your scheduled time.

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I have neck pain. I have thoracic pain. I have lower back pain. My neck hurts. My back hurts.I have sciatica.My legs hurt. I have dizziness. I have buzzing of the ears. I have blurred vision. My body feels numb. I have headaches. I have migraine headaches. I have cluster headaches. I have tension headaches. I have tension. I suffer pain.I have fibromyalgia. I have social anxiety disorder. I have asthma. I have Otis media. I have ear infections. My immune system is not functioning well. I am not healthy. I want to be healthy.My back hurts. My lower back hurts. My hips are painful.I have bowel problems. I have bladder problems. Canadian chiropractic association. Ontario chiropractic association. Kitchener chiropractors. Kitchener Ontario chiropractors. Kitchener chiropractors Ontario. Kitchener Waterloo chiropractors. Chiropractors in Kitchener Waterloo. Kitchener Waterloo chiropractors Ontario. www.chiromax.com. www.icpa4kids.org. www.chiropractic.on.ca. I need rehabilitation. motor vehicle accident. Workers compensation. Workman's compensation. WSIB. Car accident. I have whiplash. My muscles are tight. I need a massage. Massage therapy. I have sciatica. My legs hurt. My arms hurt. I have carpel tunnel syndrome. Carpel tunnel syndrome. Rotator cuff syndrome. I have tendinitis. Tendinitis. I have irritate bowels. I have bladder problems.
I have digestive problems. I have stomach pain. I have heartburn. My arm hurts. My leg hurts. My shoulder hurts. Chiropractic. chiropractor. Stress management. Nervous system. Subluxation. Adjustment. Nerve interference. Sympathetic Nervous System. Parasympathetic Nervous system. Autonomic nervous system. Dr. Steven Murdoch. Dr. Steven P Murdoch. Fairway chiropractic centre.