Chiro new patient form

New Patient Form

Please fill out as much of this form as possible. All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.
Have you been overseas in the past 14 days?’ and/or ‘Have you been displaying any fever-like symptoms?’and/or "have you been in contact with anyone diagnosed with COVID-19"?*

YesNo
1. Full Name*

First NameLast Name
Birth Date*

DayMonthYear
2. Address

Street Address

Street Address Line 2

CityState / Province

Postcode
Mobile Phone
Home Phone
Email (for appointment reminders)
Your Occupation
8. Have you had spinal x-rays before?

NoOther
9. Area of discomfort or pain

Headache/migraineLeftRightNeckLeftRightShoulderLeftRightMid backLeftRightLow backLeftRightHipLeftRightArmLeftRightLegLeftRightChestLeftRightOther
10. Have you had this injury before?

NoOther

11. Level of pain today

	1	2	3	4	5	6	7	8	9	10

1 is very little, 10 is very painful

12. How did it happen?

LiftedBent overFallGetting up from sittingWoke up with itSportWorkCar accidentNot sureOther
13. Onset of Discomfort or Pain

SuddenGradualWoke up withWoke me upOther
14. Frequency - please select the most accurate

ConstantOff/OnAt RestWith ActivityOther
15. At what time of day is the pain at its worse?

MorningAfternoonEveningDuring SleepOther
19. Getting better or worse
When?
21. Have you consulted a Chiropractor before today?

NoOther
22. Have you ever been in an accident (automobile, work, falls, etc.) ?

YesNoOther
24. List any broken bones and year
23. List any previous operations and year
25. Are you currently taking any medications?

NoOther
26. Please tick if you have had any of the following in the past month or since the onset of your main presenting health problem:

NauseaFever or rashesFatigue not resolved by sleepUnexplained weight loss/gainChanges to hair, skin or nailsDifficulty breathingChest pain or discomfortFainting or loss of consciousnessDecreased urinary or bowel controlPain or blood loss during urination or bowel movementsOther
27. Please tick if you have had any of the following:

High Blood PressureHigh CholesterolAnaemia/low iron levelsThyroid problemsCancerDiabetesAllegeries or other immune related conditionsBone or joint diseases - arthritis, osteoporosis, pagetsOther vascular conditionsAsthmaWhiplashStrokeOther
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Date*

MonthDayYear
Name*

First NameLast Name
Signature:

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