Initial Consultation Intake: Adult

Welcome to Heal Chiropractic! Please take a moment to fill out our online intake form, this is the first insight our team gets into YOU, it helps us to understand your main concerns, important clinical history, lifestyle factors and most importantly what you are hoping to achieve from care. All information is kept completely confidential. Complete these with intention, take your time, we want to gather as much information as we can so we can ascertain how it is that we can serve you best.

First Name:

Last Name:

Phone:

Gender:

Male Female

Address

DOB:

Age:

Email:

Occupation:

Private Health Fund:

Marital Status:

Partner/Spouse Name:

Are you filling this form out for a child?

Yes No

Number of Children:

Name of Children

1.Many patients are referred to our office by family or friends. Who can we thank for referring you?

2. Spinal health is important for overall movement and function. When was your last spinal check-up, including x-rays?

3. How Often do you get adjusted by a chiropractor?

Frequently Only when it hurts 1x Month Never

4. Do you notice any sounds (e.g., grinding or cracking) when moving your neck or back?"

Yes No

5. Do you frequently feel the need to stretch, adjust, or self-crack your neck or back

Yes No

6. Posture can influence musculoskeletal health and comfort. How would you describe your posture?

Poor Fair Good Excellent

7. Stress can contribute to muscle tension and discomfort. How would you rate your current stress level?

Poor Fair Good Excellent

8. Spinal and musculoskeletal health can influence how you feel. Please SELECT or LIST any symptoms or discomfort you are experiencing:

Allergies Thyroid Heart Disease Asthma Diabetes I/II Menstrual Pain Digestive (Constipation/IBS) Headaches/Migraines Neck Pain L/R Arm Pain L/r Mid Back Pain Low Back Pain Leg Pain

Anxiety or depression

Auto-immune disease

Allergies

9. Some medications may have side effects. If you are taking any prescription or over-the-counter medications, please list them below:

10. Please list any surgeries you have had:

11. Pregnancy can bring changes to posture and spinal comfort. Are you currently pregnant?

12. Sleeping positions can influence spinal comfort and posture. What sleeping position do you typically sleep in?

Back Stomack R Side L Side

13. Exercise Level

Poor Fair Good Excellent

Patient Signature:

Date:

Profile Information:

First Name:

Last Name:

Preferred Name:

Pronouns:

Prefix/Title:

Occupation:

Phone:

DOB:

Address

Gender:

Sex:

Emergency Contact:

Emergency Contact Phone:

Emergency Contact Relationship:

Family Doctor Phone:

Marital Status:

Partner/Spouse Name:

Number of Children:

Name/Age of Children

Is there a chance you may be pregnant?

Yes No

Number of past pregnancies

If yes, how many weeks?

Any health concerns, related to this pregnancy?

The research tells us that your spine, just like your teeth, need to be cared for regularly.

Have you seen a Chiropractor before?

Yes No

If YES, when were you last adjusted? And who was your Chiropractor?

If YES, how often do you get checked by a Chiropractor?

Frequently e.g. weekly, fortnightly, monthly Only when I'm in pain

Has your family seen a Chiropractor Before?

Yes No Some Family Members

Many of our practice members are referred into our office by a family member or friend. Who can we thank for referring you to us? OR what made you decide to visit our practice?

Nervous System Review

Please select if you are currently experiencing any of these symptoms/health concerns or if you have experienced in the past.

Headaches Migraines Painful/Clicking Jaw Teeth Grinding Mouth Breathing Dizziness Nausea Numbness Pins & Needles Low Energy Fatigue/Exhaustion Reflux Vomiting Constipation Diarrhoea Bloating Food Sensitivities Allergies Asthma Recurrent Colds/Flus/Infections Sinus Issues Snoring Shortness of Breath Chest Pain Heart Palpitations High/Low Blood Pressure Cold Hands/Feet Bedwetting Poor Sleep Stress Anxiety Depression Mood Disorders Sensitivity to Sound Sensitivity to Light Poor Concentration Poor Memory Poor Coordination/Clumsiness Poor Balance Poor Posture Neck Pain/Stiffness Back Pain/Stiffness Shoulder Pain/Stiffness Hip Pain/Stiffness

Other, please specify

Spinal Health Review

When was your last complete spinal examination (and x-rays if applicable)?

Do you know if you have spinal curvature? Spinal arthritis? OR Other concerns related to your spinal health e.g. inherited condition?

Overtime spinal misalignment causes arthritis and degeneration, this can result in restricted movement in your neck and back and/or grinding, popping or cracking sounds with movement.

Do you find it difficult to move your neck/back?

Yes No Sometimes

Do you find it painfult to move your neck/back?

Yes No Sometimes

If your spine is out of alignment for a long time it can make you feel like you need to stretch, twist or crack your own neck/back. Do you experience this?

Yes No Sometimes

Do ou have any concerns related to your posture?

Supplements and Medications:

Please list any supplements or medications you are currently taking and your reasons for taking them?

Please list any supplements or medications you have taken in the past and your reasons for taking them?

Illness and Injury:

Hospitalisations

Major Falls/Accidents/Traumas: e.g. motor vehicle accidents, sporting injuries etc.

Recurrent illness e.g. colds/flus/infections etc.

Chronic illness e.g. autoimmune disease, diabetes, thyroid conditions, cancer etc.

Mental health disorders e.g. anxiety, depression, ptsd etc.

Please list any past sugeries

General Health Review

Physical, chemical and emotional stressors can contribute to spinal misalignment, accelerate spinal damage and adversely effect the health of your nervous system and overall health.

Please list your top physical stressors (e.g. any motor vehicle or other accidents, workplace, sporting or other injuries, slips/falls, poor posture, sitting for long periods etc.)

Please list your top chemical stressors (e.g. dehydration, smoking/vaping, alcohol consumption, poor diet, exposure or workplace chemicals such as pesticides, fumes, chemicals, cleaning products etc.)

Please list your top emotional stressors (e.g. mental health concerns, trauma, work/study related stress, relationship stress etc.)

Poor sleep posture can cause spinal misalignment. What position do you sleep

Back Stomach Left Side Right Side

What is your current level of physical activity?

What do you currently do as your main form of exercise/physical activity? e.g. walking, gym, sports

Do you consider your diet to be healthy/balance?

Yes No

Health Goals and Ambitions

What health outcomes and improvements would you like to acheive at House of Healing Chiropractic?

Do you consent to a thorough examination of your spine and nervous system with our Chiropractor?

Yes No

Attach Document

Signature

Thank you so much for taking the time to fill out this form for us. We're looking forward to getting to know you more!

Initial Consultation Intake: Adult

$49 NEW PATIENT SPECIAL!