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Full Name: ________________________________________________ Today’s Date: ____________________ Date of Birth: ________________________ Occupation: ___________________________________________ Mobile: __________________________________ Home Phone: ____________________________________ Email Address: _____________________________________________________________________________ Address: __________________________________________________________________________________ City: __________________________________State: _______________________ Postcode: _____________Emergency Name: ___________________________ Emergency Phone: _______________________________ Who referred to you this Chiropractic Office? GP ☐ Massage Therapist ☐ Podiatrist ☐ Google ☐ Signage ☐ Relative ☐ Word of Mouth ☐ Name:_______________________________________________ Reason for Care Specific Concern ☐ Chiropractic Spinal Check-up ☐ Main concern: __________________________________________________ What do you think caused this problem? _____________________________ ______________________________________________________________ How long have you this problem? ___________________________________ Is it… Getting Better ☐ Getting Worse ☐ Staying the Same ☐ On/Off ☐ Rate the severity: 0 1 2 3 4 5 6 7 8 9 10 Describe the nature of your symptoms: ☐ Sharp ☐ Ache/Dull ☐ Stabbing ☐ Burning ☐ Throbbing ☐ Shooting ☐ Radiating ☐ Tightness ☐ Stiffness ☐ Numbness ☐ Tingling Details: ___________________________________________________________________________________ Are you currently OR have you previously (please circle) received treatment for the above symptoms from any other practitioners? Chiro ☐ Physio ☐ GP ☐ Massage Therapist ☐ Naturopath ☐ Specialist ☐ Other:______________ Length of care (weeks, months etc): ____________________ Outcome of care: ________________________ Have you had any X-rays or scans for this complaint? Yes ☐ No ☐ Details (date, area, type):____________________________________________________________________ Please mark your areas of pain Patient information contained within this form is considered strictly confidential. Your responses are important to help us better understand the health issues you face and ensure the delivery of the best possible treatment. L R L R

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Page 1: Today’s Date: City: Emergency Name - Squarespace · PDF file☐ Shooting ☐ Radiating ☐ Tightness ... Please mark your areas of pain Patient information contained ... Has anyone

FullName:________________________________________________Today’sDate:____________________

DateofBirth:________________________Occupation:___________________________________________

Mobile:__________________________________HomePhone:____________________________________

EmailAddress:_____________________________________________________________________________

Address:__________________________________________________________________________________

City:__________________________________State:_______________________Postcode:______________

EmergencyName:___________________________EmergencyPhone:_______________________________

WhoreferredtoyouthisChiropracticOffice?GP☐MassageTherapist☐ Podiatrist☐Google☐

Signage☐Relative☐WordofMouth☐Name:_______________________________________________

ReasonforCareSpecificConcern☐ ChiropracticSpinalCheck-up☐

Mainconcern:__________________________________________________Whatdoyouthinkcausedthisproblem?_____________________________

______________________________________________________________

Howlonghaveyouthisproblem?___________________________________

Isit…GettingBetter☐GettingWorse☐StayingtheSame☐On/Off☐

Ratetheseverity:012345678910

Describethenatureofyoursymptoms:

☐Sharp☐Ache/Dull☐ Stabbing☐ Burning☐ Throbbing

☐ Shooting☐ Radiating☐ Tightness☐Stiffness☐Numbness☐Tingling

Details:___________________________________________________________________________________

AreyoucurrentlyORhaveyoupreviously(pleasecircle)receivedtreatmentfortheabovesymptomsfrom

anyotherpractitioners?

Chiro☐Physio☐GP☐MassageTherapist☐Naturopath☐Specialist☐ Other:______________

Lengthofcare(weeks,monthsetc):____________________Outcomeofcare:________________________

HaveyouhadanyX-raysorscansforthiscomplaint?Yes☐No☐

Details(date,area,type):____________________________________________________________________

Pleasemarkyourareasofpain

Patientinformationcontainedwithinthisformisconsideredstrictlyconfidential.Yourresponsesareimportanttohelpusbetterunderstandthehealthissuesyoufaceandensurethe

deliveryofthebestpossibletreatment.

L R L R

Page 2: Today’s Date: City: Emergency Name - Squarespace · PDF file☐ Shooting ☐ Radiating ☐ Tightness ... Please mark your areas of pain Patient information contained ... Has anyone

PastHealthHistoryHaveyouhadanypreviouschiropracticcare?Yes☐No☐ IfYes;Reason:__________________________

NameofpreviousChiropractor/Clinic:_______________________________Dateoflastvisit:____________

DoyouhavearegularGP?Name:___________________________Clinic:_____________________________

Doyoutakeanymedications?Ifyes,pleaselist:(e.g.bloodthinners,painkillers,anti-depressantsetc.)

__________________________________________________________________________________________

Haveyoubeenhospitalisedrecently?☐Yes☐NoWhen:___________________________________

IfYES,why:________________________________________________________________________________

Haveyoubeendiagnosedwithanyofthefollowing?

Cancer☐Diabetes☐Stroke☐HeartDisease☐Osteoporosis☐Arthritis☐ Other:_____________

Details:___________________________________________________________________________________

Hasanyoneinyourfamilybeendiagnosedwithanyofthefollowing?

Cancer☐Diabetes☐Stroke☐HeartDisease☐Osteoporosis☐Arthritis☐ Other:______________

Details(describewhoandwhattype):___________________________________________________________

ListanySurgeries&theyeartheywereperformed:

Year TypeofSurgery Reason

Listanymajortraumas,injuries&fallsyouhavesustained:

Year Details

HaveyoueverbeeninMotorVehicleAccident?☐Yes☐No

Year Details

Page 3: Today’s Date: City: Emergency Name - Squarespace · PDF file☐ Shooting ☐ Radiating ☐ Tightness ... Please mark your areas of pain Patient information contained ... Has anyone

Althoughthesesymptomsmaynotberelatedtoyourcondition,theywillhelpustoidentifyotherhealthissuesthatmightaffectyourtreatment.

Pleasecircleifyouhaveanongoinghistoryofanyofthefollowing:

Musculoskeletal Neckpain;swollenjoints;arthritis;scoliosis;sciatica;weakness;lossofstrength

General Allergies;fatigue;fever;skinconditions;weightgain;weightloss

Psychological Anxiety;depression;stress;difficultycoping;bipolardisorder;othermentalhealthconditions

NervousSystem Dizziness;fainting;numbness;tingling;poorbalance;falls;seizures

Head Headaches;migraines;hearingloss;tinnitus;jawproblems;visualproblems;blurredvision

Heart&Circulation Abnormalheartrhythm;anemia;bloodclottingdisorders;chestpain;highbloodpressure

Lungs&Breathing Asthma;chroniccough;difficultybreathing;spittingupphlegm/blood;painfulbreathing

Abdominal Abdominalpain;bloodinstools/urine;gallbladderproblems;kidneyproblems;liverproblems;lossof

appetite;irritablebowel;reflux;nausea;vomiting

Reproductive Endometriosis;PCOS;pregnancy;testicularpain

Ifyoucircledanyoftheabove,pleaseprovidefurtherinformation:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Doyouhaveanyotherhealthissuesorconcerns?____________________________________________________________________________________________________________________________________________________________________________________________________

ConsenttoTreatmentOsseousandsofttissuemanipulationhasbeenthesubjectofmanygovernmentreportsandmulti-disciplinarystudiesandhasdemonstratedtobeahighlyeffectivetreatmentforspinalandmusculoskeletalconditions.Theriskofinjuriesorcomplicationsfromtreatmentissubstantiallylowerthanthatassociatedwithmanyothertreatments,medications,orsurgicalproceduresgivenforthesamesymptoms.However,youmustrecognisethatlikeallhealthcareprocedures,therearerisksassociatedwithassessmentandtreatment,whichyoushouldbeinformedabout:a.Whilerare,somepatientshaveexperiencedfracture,sprainorstrainfollowingtreatmentbyachiropractor;b.Therehavebeenrarelyreportedcasesofdiscinjuriesfollowingcervicalandlumbarspinaladjustmentc.Therehavebeenextremelyrarecasesofinjurytoavertebralarteryfollowingosseousspinalmanipulation.Vertebralarteryinjurieshavebeenknowntocausestroke,sometimeswithseriousneurologicalimpairment,anduncommonlyresultinparalysisordeath.Thepossibilityofinjuryresultingfromcervicalspinemanipulationisextremelylow(between1in2millionto1in5.85million-Haldeman,etal.Spinevol24-81999).

IacknowledgethatIhavebeeninformedofthepotentialrisksofchiropracticcareandIunderstandthatitisnotpossibletoanticipateallthepotentialrisksandcomplicationsthatmayresultfromchiropracticcare.IunderstandthatresultsarenotguaranteedandIrecognisethattherearealternativetypesoftreatmentavailable.Iherebyconsenttothetreatmentsofferedorrecommendedtomebymyhealthcareprovider,includingosseousandsofttissuemanipulation.IintendthisconsenttoapplytoallmypresentandfuturecareatWatersFamilyChiropractic.Today’sDate:____________Patient’sName:_____________________Patient’sSignature:____________________(Parentorlegalguardiantosignifpatientisunder18)

ParentorLegalGuardiansName:____________________________ChiropractorsSignature:____________________


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