Patient Form

What is your Gender?*

MaleFemale

Full Name*

First NameLast Name

Date of Birth:*

DayMonthYear

Occupation

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

What is your reason for your visit?:

Check the conditions that apply to you:*

Family History

Have you had any trauma or injuries before?*

YesNo

Have you had any surgery or hospitalisation before?*

YesNo

Have you been to Chiropractor and Acupuncturist before?*

YesNo

Have you had any X-ray and/or imaging?*

YesNo

Have you had any other treatment before? If Yes, please write down in the box.

Are you currently taking any OTC / Supplements or prescription medication?*

YesNo

List all OTC / Supplements or Prescription medication:

Do you have any allergies?*

YesNo

Do you smoke or drink?

YesNo

Please list any allergies:

For woman patients only - Are you going to be pregnant or getting pregnant?

YesNo

Patient Guidelines

Chiropractic and Acupuncture care processes

1.Patient fill out the form including health history

2.Examination performed by chiropractor and/or acupuncturist

3.The practitioner may touch or palpate areas of your body due to the nature of the treatment, which helps in the process of diagnosis.

4.Further examination may be required such as X-ray or ultrasound referral

5.Treatment will be done on inital visit if needed and Report of Findings will be included as follow up treatment.

In order to access parts of your body, you may be asked to remove your garments but you may get towel or blanket to cover the affected area.

You may experience some minor bleeding, bruising, swelling or numbness following the cupping treatment.

Fainting can occur in certain patients particularly at the first treatment.

In addition, if there are particular risks that apply to your case, your practitioner will discuss these with you.

Written consent by parent or guardian may be required if the patient is under 18 years of age.

I agree that collection and passing of my information among other health professionals is permitted wihen it is necessary for specific purposes in terms of the Privacy Act 1993 and the Health information Privacy Code 1994.

Patient Declaration

I understand, have read and completed this questionaire truthfully. I agree that this constitutes full disclosure, and that it supercedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or complications from treatments received. I am aware that it is my responsibility to inform the medical staff of my current medical and/or health conditions and to update this history. The treatments I receive are voluntary and I release Otahuhu Chiropractic Acupuncture, it's health professionals and staff from liability and assume full responsibility thereof.

Patient Signature:

Date:*

DayMonthYear

Medical History