Clinic Questionnaire

The initial intake form is important because many health problems can mimic disorders of the spine. This establishes your health background, for things such as surgeries, accidents, the onset of your immediate condition, and other details affecting current health. Examining your history also helps the chiropractor determine whether the immediate reasons for your consult is, in fact, spine-related.

Please fill out all information to the best of your ability and note patients who have reservations about ticking any questions may discuss these with the Chiropractor personally. 

All case histories are treated with absolute confidentiality.

PERSONAL INFORMATION
Title
Name *
Name
DD / MM / YYYY
If under 18, please also complete the box below
Parent or legal guardian's full name
Parent or legal guardian's full name
Address *
Address
If you do not have a regular GP - Who did you see last. If you don't have one - tick "I don't have one"
We need to know this as some health funds require specific item numbers
Are you covered for chiropractic care?
Is this related to either:
We are grateful that our practice grows by referral
Have you ever seen a chiropractor before?
Major Complaint
include symptoms such as type/location/radiation/duration
include information such as history/causation
Describe character of pain
Frequency of complaint
Duration of Main Complaint
Was there any of the following prior to or during the onset?
Please tick
Please specify if you ticked 'Other significant event'
Is the problem getting worse?
Comment:
Are your symptoms worse at night or any specific time of the day?
If yes, comment:
Does your current problem involve any of the following sensations?
Please specify body region if you ticked any of the above boxes
Have you had any other treatment for your current problem?
Medical History & General Health
Please mark Yes or No, and COMMENT where applicable
Did you / Do you smoke?
Number of cigarettes
Did you / Do you drink alcohol?
Comment:
Do you have a healthy diet?
specific diet
How often do you exercise?
Main sport or activity
How long do you typically sleep per night?
Character of sleep
Have you had any imaging of your spine?
MRI, X-ray or CT scan of your neck, thoracic spine or low back.
Have you had any form of surgery?
Are you currently taking any form of medication?
including any over-the-counter medicine
Are you currently taking any form of vitamins or supplements?
Do you have, or have you ever had, a serious health problem such as hypertension, heart disease, diabetes or any form of cancer?
Have you had any broken bones, sports injuries, bad falls, accidents or dislocations?
If yes, please specify
Have any of your family members suffered from any serious or hereditary diseases?
(e.g. cancer, diabetes, heart disease or any other major health problem)
Do you wake up with stiffness or aching in your joints or muscles?
Comment:
Are you often troubled by headaches?
Comment:
If so: Are they throbbing and accompanied by sickness?
Comment:
Have you had any persistent changes in your appetite during the last three months?
Comment:
Has your weight changed more than 4 kg in the last year?
Comment:
Have you had any changes to your bowel or bladder patterns?
Comment:
Do you suffer from a cramp-like pain in either leg when walking?
Comment:
Have you any lumps, cysts, or unusual swellings anywhere on your body?
Comment:
Does stress seem to make your main problem worse?
Comment:
Do you have difficulty concentrating?
Comment:
Are you subject to blackout, dizzy spells, or faints?
Comment:
Do you get car/motion sickness?
Comment:
Do you have poor balance?
Comment:
MEDICAL CORRESPONDENCE AND REFERRAL
Do you give consent for your clinical information to be communicated to your general practitioner or preferred health practitioner? *
Our practice specialises in treating problems of the spine and associated disorders of the nervous system. A proportion of our patients come via referral from their medical practitioner. As such, it is standard practice to correspond with your medical practitioner where appropriate.

 

17 Wittenoom Street,
East Perth WA 6004

☎︎ 08 9221 8458

info@spinesportscentre.com.au