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New Client Details
Please fill in the form below
Name
*
First Name
Last Name
Address:
Street Address
Street Address Line 2
Town
State / Province
Post code
Home Phone Number:
-
Area Code
Phone Number
Mobile Number:
*
E-mail:
*
Birth Date
*
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Year
Sex:
Male
Female
Occupation:
Referred by:
*
Please Select
Website
Sign
Friend/Colleague
Other
Whom may we thank, for referring you to us?
Friend's name
What were the key thing(s) that helped you choose us?
Eg Local, convenient, good reviews, liked out approach
Previous Chiropractic Care
*
Yes, within last 1 month
Yes, greater than 1 month ago
No
Tell us why you are coming to see us. If it is about a health challenge (main concern) then please tell us ALL about it.
*
eg I woke up with a sore neck, 3 weeks ago and it's not going away, actually getting worse,now its going into my arm and shoulder.
Please rate the Severity of this issue. If you are coming in for Wellness Care please indicate 0
*
0
1
2
3
4
5
6
7
8
9
10
Best
Worst
0 is Best, 10 is Worst
Do you have any pins and needles or numbness associated with the above issues?
*
Yes, constant
Yes, occasionally
No
includes: tingles, prickling sensations,
What positions, movements or activities make it worse?
*
eg Sit, stand, lie, bend, twist, lift?
What do you do, or take, to make it easier?
*
eg Position, activity, medication?
Have you seen any other health professional? What did they do and how did that work out for you?
*
GP, Physio, Osteopath, Acupuncture, Massage
Have you had any recent investigations like MRI, XRay or ultrasound for this or a related problem? What were the results/diagnosis?
*
Any secondary or other symptoms or issue?
*
another area or body part or different type of problem
Have you had spinal surgery?
*
Yes
No
Are you prone to dizziness, blackouts or faints?
*
Yes
No
Do you get debilitating headaches?
*
Yes
No
Are you on blood thinning medication?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
If yes, is this under control?
Yes
No
Unsure
Do you have a personal history of cancer?
*
Yes
No
Do you have osteoporosis or a brittle bone condition?
*
Yes
No
Do you have any condition that has been diagnosed, medicated or under care of another health professional?
*
eg Diabetes, Pacemaker, Regular cortisone, Alternative approaches
How many hours do you send sitting on an average day?
*
< 5 hours
6-8 hours
> 8 hours
How many hours do you spend in active task at home or work per day?
*
< 1 hours
1-2 hours
2-4 hours
>4 hours
Tell us about your exercise routines; types of activities; how often and how long you do them for. If you aren't exercising, please tell us your reasons why.
*
eg Daily walk for 30min, Can't do vigorous exercise because of pain
Do you smoke?
*
Yes
No
Quit
Units of Alcohol per Week
*
None
< 14 (6 pints/7 small 175ml wines)
> 14 (6 pints/7 small 175ml wines)
General
*
Headaches
Feel run down
Low sex drive
Fatigued
None
Breathing
*
Short of breath
Cough
Pain on deep breath
Phlegm
None
Circulation
*
Chest pain on exercise
palpitations/flutters
Calf Pain on walking
Cold or swollen feet
None
Digestion
*
Heartburn
Swallowing issues
IBS symptoms
Frequent burp
None
Urination
*
Burning
Discharge
Leaking (loss of control)
Decreased flow/stream
None
Female
*
Breast sweeling/tenderness
Change in period pattern/flow
Menopausal symptoms
IUD
Pill/Implant
none
Male
*
Testicle pain/swelling
none
Skin
*
Rashes
Psoriasis
Itching
none
Have you been feeling any of these lately
*
Anxious
Low/Down/Depressed
Moody/Irritable/Snappy
Unenthusiastic
None
Rate your current "Energy Levels"
*
1
2
3
4
5
6
7
8
9
10
Exhausted
Absolute Vitality
1 is Exhausted, 10 is Absolute Vitality
Rate your "Quality of Sleep"
*
1
2
3
4
5
6
7
8
9
10
Wake depleted
Wake restored
1 is Wake depleted, 10 is Wake restored
Rate your "Overall Sense of Well-Being"
*
1
2
3
4
5
6
7
8
9
10
Worst I've been
Best I've been
1 is Worst I've been, 10 is Best I've been
What are you hoping to get from your Initial Consultation & Report of Findings?
*
Find out what's going on and how to fix it.
Find out if something serious is going on.
Get rid of my symptoms
A plan/road map to help my body heal.
What do you want for your future health?
*
To feel better
Prevent future problems
Reverse effects of problems
Be as well as I can be/ Absolute vitality / Express my maximum genetic potential
Consent to Examination & Data Protection Agreement
I consent to appropriate physical examination buy the practitioner / chiropractor. (Under 16? This consent must be obtained from the parent or legal guardian - see below.)
I have read the
Data Protection Policy
and give consent to the practitioner / chiropractor to maintain records for the purpose outlined within this Policy.
Agreement and consent
*
Yes
Date:
-
Day
-
Month
Year
Date Picker Icon
If consenting for a child, please put your name and relationship to child here.
Parent/Guardian Name - relationship to child
Do you give us permissions to update your GP with your clinical info?
*
Yes
No
GP Name & Surgery
*
GP name
Surgery
Signature (if device is capable)
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