Today’s Date: City: Emergency Name - Squarespace · PDF file☐ Shooting ☐ Radiating...

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

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

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:____________________

Today’s Date: City: Emergency Name - Squarespace · PDF file☐ Shooting ☐ Radiating...

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