New Client Form

CASE HISTORY
Name(Required)
DD slash MM slash YYYY
Address(Required)
Would you like to register for online booking?
Do you wish to receive a confirmation SMS prior to your appointment?
Do you wish to receive our newsletter?
Have you ever received Chiropractic care?
Are you covered for Extras under a health fund?
What is your gender?

ABOUT YOUR HEALTH
The human body is designed to be healthy. Throughout life, events occur which damage your health expression. This case history will uncover the layers of damage, especially to your nervous system and spine that can result in poor health. Following your exam, your chiropractor will outline a course care to begin to correct these layers of damage and to help you recover your inborn/innate health potential.
PRESENT COMPLAINT / REASON FOR SEEKING CARE
DD slash MM slash YYYY
Pains are(Required)
Does the pain shoot, radiate, or travel in your body?(Required)
Do some activities aggravate your condition/pain?(Required)
Is this condition worse during certain times of the day?(Required)
Do some activities lesson your condition/pain?(Required)
What is this condition interfering with?(Required)
Is this condition getting progressively worse?(Required)
Other Doctors seen for this condition?(Required)
Any home remedies?(Required)
Please select any of the following that you have now or have experienced in the past:(Required)
Do you take any supplements / vitamins?(Required)
Have you been under medical care?(Required)
Do you take any medications?(Required)
Have you had surgery?(Required)
Have you experienced side effects from any drugs or surgery?(Required)

PRESENT COMPLAINT / REASON FOR SEEKING CARE
Have you been involved in any accidents or traumas?(Required)
Did you ever break / fracture any bones?(Required)
Did / do you smoke?(Required)
Did / do you drink alcohol?(Required)
Do you eat healthy foods?(Required)
Do you drink 8 glasses of water per day?(Required)
Do you exercise regularly?(Required)
Do you have any hobbies / sports injuries?(Required)
Did / do you have occupational stress?(Required)
Did / do you have physical stress?(Required)
Did / do you have emotional / mental stress?(Required)
Do you sleep well?(Required)
What is your sleeping posture?(Required)
Do you have a good mattress?(Required)