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"? *

Yes No
1. Full Name *

First Name Last Name
Birth Date *

Day Month Year

2. Address

Street Address
Street Address Line 2
City	State / Province
Postcode	Country

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

No
9. Area of discomfort or pain

Headache/migraine Left Right Neck Left Right Shoulder Left Right Mid back Left Right Low back Left Right Hip Left Right Arm Left Right Leg Left Right Chest Left Right
10. Have you had this injury before?

No

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?

Lifted Bent over Fall Getting up from sitting Woke up with it Sport Work Car accident Not sure
13. Onset of Discomfort or Pain

Sudden Gradual Woke up with Woke me up
14. Frequency - please select the most accurate

Constant Off/On At Rest With Activity
15. At what time of day is the pain at its worse?

Morning Afternoon Evening During Sleep
19. Getting better or worse
When?
21. Have you consulted a Chiropractor before today?

No
22. Have you ever been in an accident (automobile, work, falls, etc.) ?

Yes No
24. List any broken bones and year
23. List any previous operations and year
25. Are you currently taking any medications?

No
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:

Nausea Fever or rashes Fatigue not resolved by sleep Unexplained weight loss/gain Changes to hair, skin or nails Difficulty breathing Chest pain or discomfort Fainting or loss of consciousness Decreased urinary or bowel control Pain or blood loss during urination or bowel movements
27. Please tick if you have had any of the following:

High Blood Pressure High Cholesterol Anaemia/low iron levels Thyroid problems Cancer Diabetes Allegeries or other immune related conditions Bone or joint diseases - arthritis, osteoporosis, pagets Other vascular conditions Asthma Whiplash Stroke
Please check any symptoms that apply to you and indicate right or left when applicable:
Head

Temples Forehead Top of head In the eyes Entire head Base of skull Dizziness Fainting Light-headedness Pain in ears Ringing in ears
Neck

Stiffness Pain at neck shoulder junction Pain when turning head Pain with side to side movements Neck feels out of place Muscle spasm in neck Gliding/Grating sound with neck movement Diagnosed bone spurs Diagnosed disc herniation
Arms & Hands

Pain in upper arm Pain in forearm Pain in wrist Pain in fingers Sensation of pins & needles in arm Sensation of pins & needles in fingers Fingers go to sleep Hands cold Swollen joints in fingers Sore joints in fingers Diagnosed arthritis Loss of grip strength
Mid-Back

Mid-back pain Pain between shoulder blades Pain up/down back Pain across mid back Pain with breathing
Low Back

Low back pain Low back pain is worse when working Low back pain is worse when lifting Low back pain is worse when stooping Low back pain is worse when standing Low back pain is worse when sitting Low back pain is worse when bending Low back pain is worse when coughing Pinched nerve in low back Low back feels out of place Pain up/down low back Pain across low back Diagnosed disc herniation
Hip

Pain in buttocks Pain in buttocks when standing Pain buttocks in buttocks when sitting Pain on side of hip Pain deep in hip joint Pain on sit bone Diagnosed bursitis Diagnosed arthritis
Legs and Feet

Pain down RIGHT leg Pain down LEFT leg Pain down BOTH legs Leg cramps Pin & Needles in RIGHT leg Pin & Needles in LEFT leg Numbness in RIGHT leg Numbness in LEFT leg Numbness in RIGHT foot Numbness in LEFT foot Numbness in toes Feet feel cold Cramps in RIGHT foot Cramps in LEFT foot Swollen RIGHT ankle Swollen LEFT Ankle Swollen RIGHT foot Swollen LEFT foot Pain in RIGHT Foot Pain in LEFT Foot Pain in RIGHT knee Pain in LEFT knee Diagnosed Arthritis
Date *

Month Day Year
Name *

First Name Last Name
Signature:

Clear
Type a question
Should be Empty: