Personal History

Name: Surname:  Date:
Parents' Name (for Children):   Email:
Address: Home Phone:   Mobile:   Business Phone:
Birthdate: / /   Age:   Sex: Male / Female
Title: Miss / Mrs / Ms / Mr / Dr
Business / Employer:   Type of Work:
Referred to a particular practitioner here?:
Referred to This office by:
What motivated you to come to our centre?:
Name of Private Health Insurer:
Third Party Insurance details: Workers Compensation: Motor Vehicle:
Third Party Insurance Claim Number:

Current Health History

Condition you are consulting us for :
Other Doctors / Therapists seen for this condition? :
Types of treatment by above : Results :
When did this condition begin? : Has it occurred before? :
What aggravates this condition? : What relieves it? :
Do others in your family have a similar condition? :
Is the condition Job related ( ) Auto related ( ) Home Injury ( ) Fall ( )
                                    Other ( )
Date of incident : / / Reported to employer if work related?
If disabled from work, please give dates :
Please list any medication you are currently taking :
Do you suffer from any condition other than that for which you are consulting us now? :
Do you drink Alcohol? How much?
Do you drink Tea or Coffee? How much?
Do you Smoke? How much?
Do you exercise regularly or play sport? : Details :

Past Health History

Major surgery / operation: Appendix( ) Tonsils( ) Gall Bladder( ) Hernia( ) Heart( )
Back( ) Neck( ) Leg( ) Knee( ) Other:
Any previous lasting illness or health complaint? Current / ongoing:
Previous Chiropractic care to include doctor's name if known and approximate date of last adjustment: / /

Spinal X-Rays

A Radiological examination may be performed as part of your general examination within this clinic. The radiographs remain your property and should be stored carefully at home once released by your Chiropractor.

Patient Consent

The above information is correct to the best of my knowledge and I consent to being assessed / treated within this clinic.

Signed:

MUSCULO-SKELETAL

( ) Neck is sore / stiff / painful
( ) Midback is sore / stiff / painful
( ) Lowerback is sore / stiff / painful
( ) Other joints - pain / stiffness - if so
           where? :
( ) Walking problems
( ) Painful tailbone
( ) Arm or leg pain / stiffness
( ) Nervousness

NERVOUS SYSTEM

( ) Numbness - state where :
( ) Paralysis - state where :
( ) Dizziness
( ) Thickhead feeling
( ) Previous cranial (head) injury
( ) Headaches
( ) Fainting
( ) Convulsions / epilepsy
( ) Confusion / depression

GENERAL

( ) Allergies
( ) Loss of sleep
( ) Fever
( ) Nervousness
( ) Skin rash
( ) Skin eruptions
( ) Asthma
( ) Bladder control
( ) Diabetes

EYES / EARS/NOSE / THROAT

( ) Vision problems
( ) Orthodontic work - previous / current
( ) Dental operations / problems
( ) Sore throat
( ) Earache
( ) Hearing problems
( ) Blocked nose
( ) Other

CARDIO / RESPIRATORY

( ) Angina
( ) Chest pain
( ) Shortness of breath
( ) Blood pressure trouble
( ) Irregular heartbeat
( ) Heart problems
( ) Lung problems
( ) Other

GASTRO INTESTINAL

( ) Poor / excessive appetite
( ) Excessive thirst
( ) Frequent nausea
( ) Vomiting
( ) Diarrhoea
( ) Constipation
( ) Liver trouble
( ) Gall Bladder trouble
( ) Weight trouble
( ) Abdominal cramps

FEMALE REPRODUCTIVE SYSTEM

( ) Menstrual irregularity
( ) Menstrual cramping
( ) Vaginal pain / infection
( ) Breast pain / lumps
( ) Excessive menstrual flow
( ) Hot flushes
( ) Monthly backaches
( ) Miscarriage history
( ) Difficult birth : ( ) C-section ( ) Long labour
( ) Forceps ( ) Induced labour ( ) Suction delivery
( ) Are you pregnant? ( ) Yes ( ) No ( ) Maybe

Please outline on diagram the area/s of :

		Pain Ache
		Pain Ache
		Pain Ache
		Pain Ache
		Pain Ache
		Pain Ache
		Pain Ache
		Pain Ache