Back Doctor Chiropractic History Form

New Patient Form
Welcome to Back Doctor Chiropractic Clinic!

We are delighted that you have chosen Back Doctor Chiropractic to begin your journey to better health. Before you come to see one of our chiropractors we ask that you take some time to fully complete this questionnaire so that we more fully understand your health needs. If you have any questions or require further help please contact the clinic on 01745 535854 or admin@back-doctor.co.uk

Back Condition Information
Only complete this section if your problem includes pain in your lower back or buttocks, otherwise please move onto the next section.

For this set of questions, please think about your back pain over the last two weeks.
Overall, how BOTHERSOME has your back pain been in the LAST 2 WEEKS?

Not at allSlightlyModeratelyVery MuchExtremely

Please read the following concerning the possible risks and side effects of chiropractic treatment.

It is common for patients to feel sore after treatment for one or two days.

There are rare cases of sprains/strains following treatment.

Adjustments in the rib region have been known to cause rib fracture/dislocation. This is an extremely uncommon occurrence.

There have been rare reports of cervical or lumbar disc damage following an adjustment, but there is no evidence that it was caused by the adjustment.
I have read and considered the risks of and I consent to examination and treatment. Please sign! *

Clear
Date*

DayMonthYear
Date
I am happy to receive communications from the clinic*

YesNo
I am happy for you to contact my GP or insurance company. I understand that you will not do this before asking me again verbally.*

YesNo
Thank you for completing this questionnaire. You will receive other forms during the course of your treatment to help us assess the effectiveness of our treatment and to give you the opputunity to feedback to us. You will receive the first form by email shortly.
Should be Empty:

New Patient Form