Back Doctor Ongoing Form

Risk Assessment
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

Level of Urgency Assessment
Where would you put your pain level where 10 is the worst pain imaginable and 0 is no pain *
Is the pain getting worse? *

Yes No
Have you tried pain relief? *

Yes No
Have you tried exercise? *

Yes No
Have you sought professional advice *

Yes No
If you think your problem is urgent, please explain why? *

I have discussed the risks of treatment with my chiropractor, especially in relation to COVID 19 transmission and I consent to examination and treatment *

Clear
Date *

Day Month Year
Date
Should be Empty:

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Risk Assessment