New Client Form – North Lakes

CASE HISTORY
Name *
DOB *
Address *
Suburb *
Postcode *

Would you like to register for online booking? *

Do you wish to receive a confirmation SMS prior to your appointment? YesNo

Do you wish to receive our newsletter? YesNo

How did you find out about our practice? *

Please tell us how you found out about our practice. Who may we thank for referring you? *

Have you ever received Chiropractic care? * YesNo

Chiropractors name *

Are you covered for extras under a health fund? * YesNo

Health Fund *

What is your gender? * MaleFemale

Date last Menstrual Period began on? *

Are you possibly Pregnant? * YesNo

What is your due date? *


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:

Major Complaint *

Pain or Problem started on *
Pains are * SharpDull / AcheConstantIntermittentOther
Describe the pains *

Does this pain shoot, radiate, or travel in your body? * YesNo

Where does the pain shoot, radiate, or travel in your body? *

Do some activities aggravate your condition/pain? * YesNo

What activities aggravate your condition/pain? *

Do some activities lessen your condition/pain? * YesNo

What activities lessen your condition/pain? *

Is this condition worse during certain times of the day? * YesNo

When in the day is condition worse? *

What is this condition interfering with? WorkSleepRoutineNothingOther

Please tell us what else this condition is interfering with *

Is this condition getting progressively worse? * YesNo

Please provide details on how condition is getting worse: *

Please select how you feel (0 = No Pain, 10 = Worst) *

Other Doctors seen for this condition? * YesNo

Doctors name *

Any home remedies? * YesNo

Details of home remedies *

Please tick any of the following that you have now or have experienced in the past:

AllergiesAsthmaCancerChest PainsConstipationDepressionDiabetesDiarrheaDizzinessFatigueFeverHeadachesHeart Attack
High Blood PressureIrritabilityJoint SwellingLights Bother EyesLoss of BalanceLoss of Smell or TasteLow Back PainMemory LossMenstrual CrampsNeck PainNeck StiffNervousnessNumbness in Hands or Arms
Numbness in Legs or FeetPain Between ShouldersPain in Hands or ArmsPain in Legs or FeetPainful UrinationShortness of BreathShoulder PainSinusSleeping ProblemsStomach UpsetStrokeTensionWeight Loss

Do you take any supplements/vitamins? * YesNo

What supplements/vitamins do you take? *

Have you been under medical care? * YesNo

Do you take any medications? * YesNo

What medications are you taking? *

How long have you taken these medications? *

Have you had surgery? * YesNo

Type and date of surgery? *

Have you experienced side effects from any drugs or surgery? * YesNo

Please provide details of side effects from any drugs or surgery: *


CURRENT HEALTH HABITS

Have you been involved in any accidents or traumas? * YesNo

Please provide details of dates and injuries *

Did you ever break/fracture any bones? * YesNo

Please provide details *

Did/do you smoke? * YesNo

Please provide details on amount and years *

Did/do you drink alcohol? * YesNo

Please provide details on alcohol consumption *

Do you eat healthy foods? * YesNo

Please provide details on eating habits *

Do you drink 8 glasses of water per day? * YesNo

Do you exercise regularly? * YesNo

Please provide details on your exercise *

Do you have any hobbies/sports injuries? * YesNo

Please provide details on hobbies/sports injuries *

Did/do you have occupational stress? * YesNo

Please provide details on occupational stress *

Did/do you have physical stress? * YesNo

Please provide details on physical stress *

Did/do you have emotional/mental stress? * YesNo

Please provide details on emotional/mental stress *

Do you sleep well? * YesNo

Please provide details on your sleep issues *

What is your sleeping posture? * SideBackStomach

What type and how many pillows do you sleep on? *

Do you have a good mattress? * YesNo

Please describe your mattress *

How would you currently rate your health? (1 is poor and 10 is exceptional) *

Why are you looking to receive care? *

How does this condition impact your life? *

Why do you think your body hasn't recovered on its own or from other therapy? *

What results are you expecting and in what time frame? *

When you achieve your desired results, what overall positive difference will this make in your life? *