Health History
Please complete the below form
Name
Mr.
Mrs.
Miss.
Ms.
Other
Title
First Name
Last Name
Birth Date
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State
Postcode
Personal Number
Please enter a valid phone number.
Format: 0000 000 000.
Work Number
Please enter a valid phone number.
Format: 0000 000 000.
Email
example@example.com
Relationship Status
Please Select
Single
Married
Widowed
De Facto
Number of Children
Please Select
0
1
2
3
4
5+
Children Age
Emergency Contact
Number
Please enter a valid phone number.
Format: 0000 000 000.
Occupation
I was recommended this clinic by
Do you have Private Health Insurance?
Please Select
Yes
No
Does it cover Chiropractic?
Please Select
Yes
No
Do you have a Concession Card?
Please Select
Yes
No
What symptoms/conditions do you have? (e.g. low back ache, pins and needles in left leg, etc.)
Please mark on this diagram where you are experiencing pain/discomfort
How long have you had symptoms for?
What aggravates your condition?
What relieves your condition?
What treatment, if any, have you had? (e.g. medical, chiropractic, physiotherapy, acupuncture, kinesiology, etc)
Treatment goals: why is it important to treat your symptoms now? (e.g. return to employment, improve sleep, sport, etc.)
Prescription Medication
Over the counter medication/supplements (vitamins, minerals, herbs, etc)
Is there anything else I should know before we begin?
Have you experienced any of the following?
Sports Injuries
Please Select
Yes
No
Unsure
Comment
Car Accident
Please Select
Yes
No
Unsure
Comment
Surgery of any kind
Please Select
Yes
No
Unsure
Comment
Orthodontic/Major Dental
Please Select
Yes
No
Unsure
Comment
Broken Bones
Please Select
Yes
No
Unsure
Comment
Do you have a family history of any serious illnesses?
Please Select
Yes
No
Unsure
Comment
Did you or do you currently?
Exercise
Please Select
Yes
No
Unsure
Comment
Sleep Well
Please Select
Yes
No
Unsure
Comment
Smoke
Please Select
Yes
No
Unsure
Comment
Drink Alcohol
Please Select
Yes
No
Unsure
Comment
Addiction
Please Select
Yes
No
Unsure
Comment
Work Stress
Please Select
Yes
No
Unsure
Comment
Home Stress
Please Select
Yes
No
Unsure
Comment
Please tick any conditions that you have
Headaches
Neck pain
Back pain
Pop, click or jaw pain
Pins and needles
Dizziness
Loss of balance
Fatigue
Memory loss
Loss of smell
Difficulty swallowing
Bad breath
Nausea
Indigestion
Diarrhoea
Constipation
Food sensitivities
Epilepsy
Hearing problems
Loss of taste
High blood pressure
Low blood pressure
Chest pain
Shortness of breath
Muscle cramps
Fluid retention
Fainting
Eyes light sensitive
Eczema
Cancer
Kidney/Bladder trouble
Asthma
Regular colds/flu
Restless legs
Diabetes
Migraine
Vision problems
Allergies
Stroke
Name
First Name
Last Name
Signature
Date
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
PARENT/GUARDIAN TO COMPLETE IF PATIENT IS LESS THAN 18 YEARS OF AGE
Â
I
blanks
Parent/Guardian of
blank
consent to Chiropractic care.
Signature
Date
 -
Day
 -
Month
Year
2 digit day, 2 digit month, 4 digit year
1
Â
Submit
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