• New Patient Form

  • Type of Patient

  • Adult Form

    Please fill out prior to your first visit
  • Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • Your Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Do you have Children?*

  • Contact Information

  • Your Chiropractic History

  • Have you been to a Chiropractor before?*
  • How much do you know about the different types of Chiropractic Care?*

  • Symptoms or Pain

  • Symptom #1

  • Was there an injury to cause this?*
  • Is this a Workcover or TAC Claim?*
  • Have you seen anyone about this condition?*
  • Which of these areas of your life are affected by this condition?*

  • Symptoms or Pain

  • Symptom #2

  • Was there an injury to cause this?*
  • Is this a Workcover or TAC Claim?*
  • Have you seen anyone about this condition?*
  • Which of these areas of your life are affected by this condition?*

  • Symptoms or Pain

  • Symptom #3

  • Was there an injury to cause this?*
  • Is this a Workcover or TAC Claim?*
  • Have you seen anyone about this condition?*
  • Which of these areas of your life are affected by this condition?*

  • If you are experiencing more than 3 different Symptoms, please consult further at your initial consultation

  • General Health History

  • Physical

  • Have you had any surgeries?*
  • Have you had any accidents? (Car, Work, etc)*

  • Current Medicines and Supplements

    Please list any medications/drugs (prescription and non-prescription) - this includes Oral Contraceptive Pill, painkillers, chemotherapies, blood pressure medications, aspirin etc.

  • Mental and Emotional Stressors

    Have you experienced any of the following in the last five years?

  • Sudden loss of family/friend?*
  • Major financial/business loss?*
  • Bullying at home/work/school?*
  • Major relationship break up?*
  • Other mental/emotional trauma?*

  • Systems Review

    Are you currently experiencing any problems with the following? (tick)

  • Child/Adolescent Form

    Please fill out prior to your first visit

  • Your information

  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Parent/Guardian(s)*
  • Would you like information on a specific topic?*
  • Have you consulted with a Chiropractor before?*
  • Spinal X-Rays taken in the last 12 months?*
  • Any other previous imaging studies? (CT Scan, MRI, etc)*

  • Mainly for Mums

    This helps the Doctor determine any potential physical, chemical or emotional stresses to the child that can affect spine and nerve system development

  • 1. Tell us about your pregnancy:

  • Any trouble conceiving?*
  • Did you carry to full term?*
  • Describe any complications and when they occurred:

  • 2. Tell us about the delivery and birth of this child:

  • Did you use a midwife?*
  • The delivery was at:*

  • Obstetrician?*
  • Did you have a C-Section?*
  • Were forceps used?*
  • Vacuum Extraction?*
  • Were you induced?*
  • Did you have an Epidural?*
  • Was it a difficult birth?*
  • What was the baby's APGAR score? (Out of 10)

  • 3. Tell us more:

  • Did you breastfeed?*
  • Did you consume alcohol during your pregnancy?*
  • Did you smoke?*
  • Did you take any medication during your pregnancy?*
  • Any exposures to ultrasound?*

  • Mainly for Mums (cont.)

    This helps the Doctor determine any potential physical, chemical or emotional stresses to the child that can affect spine and nerve system development
  • 4. As a baby/toddler, (birth to 4 years), did any of the following occur?

  • 5. As a yound child, (5 -12 years), did any of the following occur?

  • Is your child's Vaccination schedule:*

  • Mainly for Mums (cont.)

    This helps the Doctor determine any potential physical, chemical or emotional stresses to the child that can affect spine and nerve system development
  • 6. As a child, has your child experienced:

  • Acknowledgements:

    To set clear expectations, improve communications and help you get the best results in the appropriate amount of time, please read each statement and sign below:

    1. I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my child's health. I understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct spinal misalignments/nerve stress (vertebral subluxations). Chiropractic is a separate healing art from medicine and does not proclaim to cure any names disease or entity.

    2. I grant permission to be called, texted, and/or emailed to confirm or reschedule an appointment and to be sent occasional cards, letters, emails, or health information as an extension of my care in this office.

    3. To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my child's health concern(s).

     

  • Date*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: