Patient Information Name (as appears on Medicare card)Date of Birth MM slash DD slash YYYY Age: *M/F/OtherEmail:* Street AddressCity/SuburbPostcodeHome Phone:Work Phone:Mobile Phone: *Name of Spouse (or parent, if minor) and DOB:Name/s of Children and DOB:Occupation:Employed by:Who Is Responsible For Account?Do You Have Private Health Insurance With Extras Cover? Yes No If yes, what company?Is Your Present Condition Covered By Workers Compensation? Yes No Emergency Contact: NameEmergency Contact Person NumberReferred By Friend/Relation Internet Facebook Other (Please describe) If referred by Friend/Relation, what is their name?Concession Pension Card Student Card Health C Card Child U 18 DVA SignaturePatient Case HistoryDear Patient: Please complete this questionnaire. Your answers will help us to determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.THIS IS A CONFIDENTIAL HEALTH AND ILLNESS REPORT Medical Conditions (Tick any of the following conditions you have had or have) Allergy Dizziness Fatigue Headache Loss of sleep Nervousness Numbness Stroke Diabetes Belching Colon trouble Constipation Diarrhea Difficult digestion Gall bladder Hemorrhoids Liver trouble Nausea Poor appetite Hiatus Hernia Chest pain Chronic cough Difficult breathing Asthma Bruise easily Dryness Itching Psoriasis Low back pain Neck pain Pain between shoulders Swollen joints Arm pain Leg pain Knee pain Foot pain Ankle pain Hand pain Earaches Enlarged glands Eye pain Sinus problems Blurred vision Hearing loss Excessive menstrual Irregular cycles Painful menstruation Vaginal discharge Fibroids Thrush Blood pressure Poor circulation Rapid heartbeat Slow heartbeat Swelling of ankles Heart Attack Car Sport Work Front sleeping Falls Repetitive Birth Bed wetting Frequent urination Painful urination Kidney infection Prostate trouble Testicular pain Have you been in a motor vehicle accident? Past year Past 5 years Over 5 years Never Describe accident details (front end/rear-end/T-bone? + any symptoms)Have you had chiropractic care before? Yes No When?Where?Doctor's NameWhat is your major complaint? Please describe and circle affected areas on diagram to right:Other complaints (Please list all and describe):How long have you had your major complaint(s)?Have you had this or similar conditions in the past? Yes No When did it start?How and why did it start?What activities aggravate your condition?What relieves your condition?Is this condition getting progressively worse? Yes No Is it: Constant Comes and goes Is this condition interfering with your: Work Sleep Daily routine Other If other, describe:Life effect: how does this symptom impact your life?How long has it been since you felt good?Exercise programs & sports:List surgical operations and years:Are you pregnant? Yes No Due Date: MM slash DD slash YYYY Your Medical Dr. is: (Name & Clinic)FAMILY HEALTH INFORMATION (columns: NAME, RELATION, PAST & PRESENT HEALTH PROBLEMS)NAMERELATIONPAST & PRESENT HEALTH PROBLEMS Add RemoveDO YOU: Now take any vitamins or minerals? List details:Now take drugs of any kind? List details:GOALS - Tick all the goals you want to achieve: Relief Mobility Back to work Correction Better sleep More energy Well-functioning Healthy Maintaining Living a wellness Prevent future injuries IMPACT OF YOUR SYMPTOMSHow is this symptom/condition interfering with your life? (Tick appropriate box.)Work Effect No Effect Mild Effect Moderate Effect Severe Effect Energy Effect No Effect Mild Effect Moderate Effect Severe Effect Exercise Effect No Effect Mild Effect Moderate Effect Severe Effect Attitude Effect No Effect Mild Effect Moderate Effect Severe Effect Recreation Effect No Effect Mild Effect Moderate Effect Severe Effect Patience Effect No Effect Mild Effect Moderate Effect Severe Effect Relationships Effect No Effect Mild Effect Moderate Effect Severe Effect Productivity Effect No Effect Mild Effect Moderate Effect Severe Effect Sleep Effect No Effect Mild Effect Moderate Effect Severe Effect Creativity Effect No Effect Mild Effect Moderate Effect Severe Effect Self-Care Effect No Effect Mild Effect Moderate Effect Severe Effect Other Effect No Effect Mild Effect Moderate Effect Severe Effect How committed are you to correcting this issue? 1 2 3 4 5 6 7 8 9 10 PLEASE TAKE A MOMENT TO UNDERSTAND THE DIAGRAM ABOVE.A. What number do you think represents your health today? 1 2 3 4 5 6 7 8 9 10 B. In what direction is your health currently headed? Gettingmuch worse Getting worse Staying about the same Getting better Getting much better Other (Please describe) PLEASE TAKE A MOMENT TO UNDERSTAND THE DIAGRAM ABOVE.TICK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD OR HAVE NOWDO YOU: Now take vitamins or minerals?Now take drugs of any kind?Spinal examination Less than 6 months 6-18 months Over 18 months Never Physical examination Less than 6 months 6-18 months Over 18 months Never Blood test Less than 6 months 6-18 months Over 18 months Never Chest x-ray Less than 6 months 6-18 months Over 18 months Never Spinal x-ray Less than 6 months 6-18 months Over 18 months Never Dental x-ray Less than 6 months 6-18 months Over 18 months Never Urine test Less than 6 months 6-18 months Over 18 months Never DATE OF LAST Please Bring Your Medicare Card To Your ConsultationMedicare NameMedicare NumberMedicare CardMax. file size: 256 MB.
