Spinal Care Chiropractic New Patient Intake Form
For Patient aged 13 years old and over
Patient Name
*
Mr.
Ms.
Mrs.
Dr.
Atty.
Engr.
Prefix
First Name
Middle Name
Last Name
Suffix
Patient Birth Date
*
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Day
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1921
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Year
Age
Occupation
*
Mobile Number
*
-
09xx
xxxxxxx
Alternate Mobile Number/ Landline
*
-
Area code or 09xx
xxxxxxxx
Patient E-Mail
*
Confirmation Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Not from Metro Manila: how long are you here for?
*
Please Select
N/A
Less than 1 week
1 week
2 weeks
2-4 weeks
1-6 months
More than 6 months
Please choose N/A if you live in Metro Manila.
Not from Metro Manila: Ave travel time to the clinic?
*
Please Select
2-4 hours by car/bus
4-8 hours by car/bus
8-12 hours by car/bus
12+ hours by car/bus
1-2 hours by plane
2-4 hours by plane
more than 4 hours by plane
N/A
Please choose N/A if you live in Metro Manila.
How did you learn about the clinic?
*
Please Select
Google/ Search Engine
Facebook
Instagram
YouTube
Referred
If Referred, name of person who referred you
*
Write N/A if not referred
PWD or Senior Card Holder?
*
Please Select
PWD
Senior
N/A
.
PWD or Senior Card Number
*
Write N/A if no ID
PWD Issue Date
*
Write N/A if no ID
Disability Type
Write N/A if no ID
Issued by (City)
Write N/A if no ID
Emergency Contact Person
*
Emergency Contact Number
*
Relationship to Patient
*
Please Select
Parent
Grandparent
Relative
Spouse/ Partner
Friend
Have you been to a Gonstead chiropractor before?
*
Please Select
Yes
No
Unsure
Do you have full spine X-Rays (A-P and Lateral)?
*
Please Select
Yes
No
Do you have previous MRI or CT Scans?
*
Please Select
Yes
No
Date of Scan?
*
Write N/A if not applicable
Previous chiropractor?
*
Name of chiropractor and clinic or write N/A if none
Date of last chiropractic visit?
*
Write N/A if not applicable
How many sessions have you had?
*
Write N/A if not applicable
Reasons for changing chiropractors?
*
Costs (Too expensive)
Location (Too far or overseas)
Unhappy with results
Want to try other chiropractors
Not applicable
Other
Reason for consultation. List all your health concerns/ symptoms including description, frequency, severity, when it started, what makes it better or worse.
*
Have you consulted a medical doctor (orthopaedic surgeon, etc)?
*
Please Select
Yes
No
What was the diagnosis?
*
If none, write N/A
What treatments have you tried before (medications, heat/ cold compress, Salompas/ patches, etc)? If none, write N/A
*
Do you get Acupuncture?
*
Please Select
Yes
No
How often?
*
Please Select
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
Do get regular Massage/ Karada?
*
Please Select
Yes
No
How often?
*
Please Select
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
Do you do Physical Therapy (PT)?
*
Please Select
Yes
No
How often?
*
Please Select
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
What does your PT do? (stretch, traction, etc)
*
If none, write N/A
Other medical conditions, all past surgeries, accidents, trauma (including birth trauma), and falls (minor/major).
*
Write N/A if none
Diagnosed with Osteopenia/ Osteoporosis?
*
Please Select
Yes
No
Have you had bone density scan?
*
Please Select
Yes
No
Diagnosed with Scoliosis?
*
Please Select
Yes
No
Family medical history (including spinal issues, scoliosis, arthritis, neurological disorders, etc.) Write N/A if none
*
Pregnant
*
Please Select
Yes
No
N/A
If pregnant, how many months?
*
Breastfeeding
*
Please Select
Yes
No
N/A
Lifestyle
*
Please Select
Active
Moderate
Sedentary
Stress Level
*
Please Select
Low
Moderate
High
Average time spent on computer/ laptop/ phone per day
*
Please Select
1-3 hours
3-6 hours
6-9 hours
9+ hours
How many hours do you spend sitting in the car (average/ day)?
*
Please Select
1-2 hours
2-4 hours
4+ hours
How often do you travel (fly)?
*
Please Select
0-2 times a year
3-4 times a year
4-6 times a year
6-12 times a year
more than once a month
Please list down all exercises/ sports/ stretches that you currently do.
*
If none, write N/A
Average steps (walking) per day
*
Please Select
Less than 2,000
2,000-5,000
5,000-10,000
More than 10,000
Do you go to the Gym?
*
Please Select
Yes
No
How often?
*
Please Select
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
Do you have Personal Trainer?
*
Please Select
Yes
No
Do you practice yoga ?
*
Please Select
Yes
No
How often?
*
Please Select
Daily
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
Do you practice Pilates?
*
Please Select
Yes
No
How often?
*
Please Select
Daily
2-3 times per week
Once a week
2-3 times a month
Once a month
Occasionally
Reason for yoga and Pilates
*
If none, write N/A
Preferred Sleeping Position?
*
Please Select
Back
Right Side
Left Side
Stomach
Average hours of sleep (daily)?
*
Please Select
less than 6 hours
6-9 hours
9+ hours
Number of pillows?
*
Please Select
0
1
2 or more
Are you RIGHT or LEFT handed?
*
Please Select
Right
Left
Both
Do you wear foot insoles/ orthotics?
*
Please Select
Yes
No
Back
Next
Please tick all symptoms that apply.
*
Please tick all symptoms that apply.
*
Please tick all symptoms that apply.
*
Back
Next
Are you willing to undergo the required posture photos, gait and balance testing, and chiropractic examination?
*
Yes
No
Are you willing to undergo the required X-rays (and other medical tests)? All patients, except children aged 0–3 years and pregnant women, are required to have a full spine X-ray (A-P and lateral views) before beginning treatment. As a Gonstead chiropractic clinic, X-rays are compulsory. They serve as a vital diagnostic tool to assess the spine’s condition, including any degeneration, curvature, or congenital defects, and to corroborate findings from the initial chiropractic examination performed during your first consultation. Most importantly, X-rays guide the chiropractor in making sure that every adjustment is carried out as specific and precise as possible. For this reason, X-rays are required regardless of whether you already have MRI results or have previously received chiropractic adjustments elsewhere. Strictly no X-rays, no adjustment.
*
Yes
No
N/A
Unsure
Currently Pregnant
If unsure or unwilling to have X-Rays done, please state reason why:
*
Pregnant
Radiation concerns
Just recently had one (within 6 months)
Already have required X-Rays
Don't see the need for X-Rays
What's your purpose or goals for seeking chiropractic care?
*
1. For chiropractic evaluation or second opinion only. Unsure if willing to proceed with treatment.
2. To try chiropractic care (maximum 1-2 sessions)
3. For short-term/ symptoms relief
(maximum 6 sessions)
4. For Spinal correction/ postural changes
5. To prevent spinal osteoarthritis/ spondylosis
6. Regular maintenance care of my spine
What activities are you unable to do now that you'd like to return to?
*
Travel
Sports
Hobbies
Daily Activities
How often can you come for adjustments?
*
Please Select
As recommended by chiropractor
Once a week
2-3 times a month
Once a month
Once a quarter
I only want 1-2 sessions
Terms and Conditions
SPINAL CARE CHIROPRACTIC is a chiropractic clinic specializing in the Gonstead technique.During your initial consultation, our goal is to provide a thorough assessment of your spinal health and guide you toward a sustainable plan for achieving your health goals and maintaining a healthy nervous system.Please note that we are not a medical clinic, hospital, or physical therapy rehabilitation center. All chiropractic adjustments are performed only by a registered and licensed chiropractor. Before recommending any treatment, our chiropractors will carefully evaluate your suitability for chiropractic care through consultation, examination, and X-ray analysis. Not all patients will be advised to undergo chiropractic adjustments. It is the patient’s responsibility to fully disclose all known medical history and health concerns during the consultation. Any findings will be clearly explained before starting care, and you will be given the opportunity to ask questions and discuss potential risks associated with chiropractic treatment.The decision to provide treatment on the same day as the initial consultation is at the discretion of the chiropractor and is generally reserved for patients who do not require X-rays, such as young children (below 4 years old) and pregnant women. Treatment may only begin once all required X-rays or other medical tests have been submitted, reviewed, and analyzed by our chiropractor.
Overview of Chiropractic Care and Chiropractors
Chiropractors are university-trained, licensed healthcare professionals who specialize in spinal health and the treatment of musculoskeletal conditions through safe and precise manual techniques. They are trained to detect and correct subluxations (spinal misalignments) and often receive more extensive training in spinal manipulation than other practitioners, making them experts in this field.In addition to adjustments, chiropractors are trained to diagnose and manage a wide range of conditions with an emphasis on spinal and nervous system function. They may use various diagnostic tools, including X-rays, and often take a holistic approach, addressing not just symptoms but also the underlying causes. Chiropractors can also provide lifestyle advice, nutrition guidance, ergonomic recommendations, and specific exercises or stretches to support overall well-being.There are many chiropractic techniques, and Gonstead, which our chiropractor specialize in, is one of the most precise. Techniques differ not only in how adjustments are performed but also in how chiropractors examine, analyze, and manage each case. While continuing care with a different chiropractor is possible, the quality of care and methods used may vary.Chiropractic care typically requires multiple sessions over time to achieve lasting results. Some patients may feel immediate relief after their first adjustment, but this is often temporary. Long-term improvement requires consistency and patience, especially for chronic issues which generally take longer to resolve than acute conditions. Because adjustments are done manually, repeated sessions are needed to create structural changes and stability in the spine.Outcomes vary from person to person, influenced by factors such as age, lifestyle, current spinal condition, overall health, genetics, compliance with recommendations, and the chiropractor’s experience. As with any form of healthcare, medical, pharmaceutical, or otherwise, results cannot be guaranteed due to these variables. Similarly, the number of sessions needed will differ for each individual.Finally, it’s important to understand that chiropractic care addresses current problems but does not permanently “fix” the spine for life. Normal aging, daily activities, stress, trauma, or accidents can all contribute to new issues over time. For this reason, regular chiropractic care is often necessary to maintain spinal health, prevent recurrence, and support overall wellness.
Fees and Termination of Treatment
All consultation and treatment fees will be charged based on the current price list and must be settled on or before the day of the appointment. Fees for the initial consultation, follow-up consultations (including X-ray reports), and treatments are billed separately. X-ray report consultations are charged independently due to the time required to analyze X-rays and prepare a personalized treatment plan. Please note that all payments are non-refundable. If you choose not to proceed with follow-up consultations or treatments, you are required to collect your CDs or films within three (3) months from your last appointment. Failure to do so will be deemed as granting Spinal Care Chiropractic Inc. permission to dispose of these records without further confirmation from you or your next of kin. Any unused treatment sessions under a package may be transferred to another individual of your choice. However, all packages must be fully consumed before their stated expiry date, regardless of whether they remain with the original patient or have been transferred to another person. It is the patient’s responsibility to assign and ensure the use of any remaining sessions should they decide to discontinue treatment.
Training Goals and Purpose
You may be asked to complete questionnaires or participate in an interview regarding your or your child’s experience. Except for relevant identifying details such as your name, address, and contact information, all other information provided may be used for the research and training purposes of Spinal Care Chiropractic Inc. and its chiropractor.
Recordings and Observations
As part of Spinal Care Chiropractic’s assessment protocols, video recordings and photographs may be taken. These are used primarily for assessment, progress tracking, and case study purposes. If recordings are to be used for any other purpose, the patient’s explicit permission will be obtained beforehand. Please note that any third-party video recording or photography of sessions, whether online or in person, requires prior approval. The sharing or posting of such recordings, including on social media or other online platforms, is strictly prohibited.
Consent, Waiver, and Release
By submitting this form and affixing your signature, you grant Spinal Care Chiropractic Inc. permission to collect your personal data for the purpose of conducting a chiropractic evaluation. You also consent to undergo a chiropractic assessment, which may include history taking, postural and gait analysis, and other relevant examination procedures.Verbal agreement to begin treatment, whether on the day of consultation or at a later date, constitutes your authorization for our chiropractor to perform chiropractic adjustments or other appropriate treatment procedures as required.Consent to receive treatment signifies your full understanding and acceptance of the treatment plan, its possible outcomes, and the associated risks. It also constitutes a waiver and release of all claims against Spinal Care Chiropractic Inc., including its officers and employees, arising from the treatments provided.Submission of this form confirms your consent and agreement to all terms and conditions stated herein.
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