Treatment Form
If this is your first visit we'd like you to fill out this form before you undergo any treatment. Any information you submit is strictly confidential and will not be passed on to third parties for marketing or other purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Email Address
*
example@example.com
Occupation
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Medical History & Injuries
*
Broken Bones / Fractures
Discoloration
Bruising
Inflammation
Cancer
Recent Surgery
Osteoporosis
Epilepsy
Arthritis
High / Low Blood Pressure
Heart Conditions
On Medication
Infections
Open Sores
Contagious Conditions
Allergy (Such as Nuts)
Edema
None of the above
Diabetes
Other
Skin Conditions
*
Acne
Rosacea
Eczema
Psoriasis
Shingles
Allergy (such as nuts / fish)
None of the above
Other
Pregnancy/ Post-Natal
In 2nd or 3rd trimeste
Breastfeeding
Other
What is the reason for your visit:
*
Headaches (e.g. tension or neck-related)
Jaw Pain or Clicking (TMJ)
Neck pain or stiffness
Shoulder Pain or Restricted Mobility
Upper Back Pain or Postural Tension
Mid-back Pain or Stiffness
Lower back pain
Sciatica or Nerve-Related Leg Pain
Hip or Groin Pain/Stiffness
Knee Pain or Instability
Leg or Thigh Muscle Strain/Tightness
Ankle or Foot Pain
Numbness or Tingling (Arms/Legs)
Elbow or Wrist Pain
Postural-Related Muscle Dysfunction
Post-Surgical or Post-Injury Rehabilitation
None of the Above
Other (please describe your symptoms)
Do any of these Headache symptoms apply to you?
Sudden severe thunderclap headache peaking within seconds or minutes
New neurological symptoms weakness numbness speech or vision changes confusion or seizure
Headache with fever rash or neck stiffness
New or changing headache in patients over 50 years old
Headache worse on lying coughing or straining
Headache during pregnancy or postpartum
Post trauma headache with vomiting or confusion
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Jaw Pain or Clicking symptoms apply to you?
Jaw pain with chest pain shortness of breath or syncope
Jaw locking or dislocation
Red hot swollen joint with fever
Jaw fracture or significant trauma
Facial numbness or weakness
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Neck symptoms apply to you?
Recent major trauma from a fall or road traffic collision
Progressive or sudden neurological deficit weakness numbness or tingling
Fever night sweats or unexplained weight loss
Unrelenting night pain or pain at rest
Neck pain with neurological or visual symptoms
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Shoulder symptoms apply to you?
Shoulder or arm pain with chest pain or shortness of breath
Obvious deformity or inability to move arm post injury
Red hot swollen joint with fever
Constant night pain or systemic symptoms
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Upper Back symptoms apply to you?
Unexplained weight loss fever or night sweats
History of cancer or long term steroid use
Pain at rest or worse at night
Neurological symptoms leg weakness numbness or incontinence
Recent trauma or suspected fracture
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Mid-Back symptoms apply to you?
Unexplained weight loss fever or night sweats
History of cancer or long term steroid use
Pain at rest or worse at night
Neurological symptoms leg weakness numbness or incontinence
Recent trauma or suspected fracture
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Lower Back symptoms apply to you?
New bladder or bowel dysfunction or saddle numbness
Progressive neurological deficit weakness numbness tingling or loss of coordination
History of cancer infection or trauma
Fever or unexplained weight loss
Severe night or rest pain
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Sciatica Type symptoms apply to you?
New bladder or bowel dysfunction or saddle numbness
Progressive neurological deficit
History of cancer infection or trauma
Fever or unexplained weight loss
Severe night or rest pain
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Hip or Groin symptoms apply to you?
Inability to bear weight after trauma
Hip pain with redness swelling or fever
Sudden leg shortening or deformity
Unexplained weight loss or fever
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Knee symptoms apply to you?
Hot red swollen joint with fever
Inability to bear weight
Severe joint effusion locking or instability
Calf swelling or tenderness
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Leg symptoms apply to you?
Severe calf pain or swelling
Redness warmth or tenderness along muscle compartments
Trauma with deformity
Systemic symptoms fever or malaise
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Foot symptoms apply to you?
Inability to bear weight after trauma
Hot red swollen joint with fever
Sudden severe pain after trauma
Severe calf pain or swelling
Systemic symptoms weight loss or fever
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Numbness or Tingling symptoms apply to you?
Sudden weakness or facial droop
Progressive or bilateral sensory loss
Loss of coordination or balance
Bowel or bladder change or saddle anaesthesia
Recurrent or unexplained falls
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Chronic Tension symptoms apply to you?
Unexplained weight loss or systemic symptoms
Pain disproportionate to clinical findings
Emergent neurological changes
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Recovery symptoms apply to you?
Wound redness swelling or discharge
Sudden loss of movement or marked increase in pain
Calf pain or swelling after surgery
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
Do any of these Elbow or Wrist symptoms apply to you?
Visible deformity or major trauma
Red warm swollen joint with fever
Numbness pallor or colour change in hand
Current fever or active infection
Deep Vein Thrombosis (DVT)
History of heart or kidney failure
None of the above
What is the pain level today?
Please Select
0 - No pain
1
2
3
4
5
6
7
8
9
10 - Very painful
When did the symptoms start?
Less than 3 weeks
3-6 weeks
More than 6 weeks
Frequency - please select the most accurate
Constant
On/Off
At rest
With activity
Other
At what time of the day is the pain at its worse?
Morning
Afternoon
Evening
During sleep
Other
Have you ever injured this area before?
Yes
No
Is there anything that you do that creates, increases or decreases pain?
If yes, please explain.
What pressure would you like for your treatment?
*
Light
Medium
Firm
Deep
Signature
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Date
*
-
Day
-
Month
Year
Date
Practitioner's Section
Practitioner Signature
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