Personal Health Personal Health Spam protection, skip this field Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Title: Dr Mr Mrs Ms Miss Full name: Preferred Name: (optional) D.O.B: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Age: I am a: Pensioner Full-time Student Concession None of the above Address: Phone: Email: Occupation: Employer: Spouse/Partner Name: Children & Age(s): (optional) Previous Chiropractic Care: (Doctor & when): I have been referred to this clinic by Mr/Mrs/Miss: Referral source: Family Friend Sign Yellow pages Website Other Emergency Contact: Phone: Current Health Condition (optional) Present problem/reason for your visit today (be brief): Please list your health issues/pains starting with your most severe How bad is it 1=Mild 10=Worst When did this episode start? If you have had this condition before, when? Did the problem begin with an injury? Major complaint is: Sharp Dull Constant Intermittent What activities aggravate your condition? What activities lessen your condition? Is your condition worse during certain times of the day? Is this condition interfering with: Work Sleep Routine Other Other (optional) Is this condition progressively getting worse? Yes No Who else have you seen for this condition? Chiropractor G.P. Physio Other: other Home remedies: How is your lifestyle affected by this condition? (e.g. Fatigue, can’t sleep, trouble gardening, etc) Other issues: Who is your medical doctor? Are you currently under drug/medical care? If so, for what condition? (optional) Current Medication(s): (optional) How long for? (optional) Are you interested in: A quick fix A lifestyle wellness program HEALTH CONCERNS (optional) Often accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this history as it will help us to help you! Have you had any surgery? (please include all surgery) Type When Doctor Accidents and/or injuries: auto, work-related, other? (Especially those related to your current problems) Type When? Hospitalised? Stressors: Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category: Physical stress (falls, accidents, work postures etc) Bio-chemical stress (smoke, unhealthy foods, missed meals, too little water, drugs/alcohol etc) Psychological or mental/emotional stress (work, relationships, finances, self-esteem etc) (optional) On a scale of 1-10 (1 = very low & 10 = extremely high) please grade your present levels of stress (including Physical, bio-chemical and psychological or mental/emotional) At work: At home: At play: Other Current symptoms (please tick the appropriate answers) Headaches Neck discomfort Pins & needles in arms Pins & needles in legs Numbness in toes Numbness in fingers Loss of balance Dizziness Sleeping problems Low back discomfort Constipation Diarrhoea Stomach upset Tension Nervousness Fatigue Irritability Chest pains Fainting Light bothers eyes Shortness of breath Cold hands Cold Feet Low BP High BP Loss of memory Burning Feet Ears ring Loss of smell Loss of taste Fever Cold sweats Buzzing in ears Anxiety Depression Other other (optional) Sleeping Posture: Side Stomach Back Are you interested in learning more about: Stress management Nutrition Exercises or stretches What was the motivating factor in your decision to book this appointment at our clinic? I consent to a professional and complete chiropractic examination and to any radiographic examination that the Doctor deems necessary. Patient Name: Signature: I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law Personal Health Copy Spam protection, skip this field Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Title: Dr Mr Mrs Ms Miss Full name: Preferred Name: (optional) D.O.B: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Age: I am a: Pensioner Full-time Student Concession None of the above Address: Phone: Email: Occupation: Employer: Spouse/Partner Name: Children & Age(s): (optional) Previous Chiropractic Care: (Doctor & when): I have been referred to this clinic by Mr/Mrs/Miss: Referral source: Family Friend Sign Yellow pages Website Other Emergency Contact: Phone: List of current health issues (optional) How bad is it? 1=Mild 10= Worst (optional) When did this episode start? (optional) If you have had this condition before, when? (optional) Did the problem begin with an injury? (optional) Major complaint is: Sharp Dull Constant Intermittent What activities aggravate your condition? What activities lessen your condition? Is your condition worse during certain times of the day? Is this condition interfering with: Work Sleep Routine Other Other (optional) Is this condition progressively getting worse? Yes No Who else have you seen for this condition? Chiropractor G.P. Physio Other: other Home remedies: If so, for what condition? (optional) How is your lifestyle affected by this condition? (e.g. Fatigue, can’t sleep, trouble gardening, etc) Other issues: Who is your medical doctor? Are you currently under drug/medical care? Current Medication(s): (optional) How long for? (optional) Are you interested in: A quick fix A lifestyle wellness program HEALTH CONCERNS (optional) Often accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this history as it will help us to help you! Have you had any surgery? (please include all surgery) Type (optional) When (optional) Doctor (optional) Accidents and/or injuries: auto, work-related, other? (Especially those related to your current problems) Type (Copy) (optional) When (Copy) (optional) Doctor (Copy) (optional) Stressors: Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category: Physical stress (falls, accidents, work postures etc) Bio-chemical stress (smoke, unhealthy foods, missed meals, too little water, drugs/alcohol etc) Psychological or mental/emotional stress (work, relationships, finances, self-esteem etc) Other Current symptoms (please tick the appropriate answers) Headaches Neck discomfort Pins & needles in arms Pins & needles in legs Numbness in toes Numbness in fingers Loss of balance Dizziness Sleeping problems Low back discomfort Constipation Diarrhoea Stomach upset Tension Nervousness Fatigue Irritability Chest pains Fainting Light bothers eyes Shortness of breath Cold hands Cold Feet Low BP High BP Loss of memory Burning Feet Ears ring Loss of smell Loss of taste Fever Cold sweats Buzzing in ears Anxiety Depression Other other (optional) Sleeping Posture: Side Stomach Back Are you interested in learning more about: Stress management Nutrition Exercises or stretches What was the motivating factor in your decision to book this appointment at our clinic? I consent to a professional and complete chiropractic examination and to any radiographic examination that the Doctor deems necessary. Patient Name: Signature: I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law Ready to Make a Change? Contact us today for more information Contact us
