Complete Chiropractic – New client intake form New patient intake form Welcome to the Complete Chiropractic new patient intake form. Please fill out this form carefully and as accurately as possible. Completing this form now will save you time on your first visit. Part 1 About you Your Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof. Your First Name * Your Last Name * Gender *MaleFemale Street Address * City * County * Post Code * Home Phone * Work Phone Email Address * Occpation *0 / 180 Date of Birth * Marital SatusSingleMarriedDivorcedCivil partnershipWidowed Partners Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof. Partners First Name * Partners Last Name * Do you have children? *YesNo Number of Children Ages of children Do you have private healthcare? *YesNo Name of your healthcare fund * Will you be claiming against your insurance? *YesNo Do you have a claim numer? Please enter if yes * Did someone refer you to the clinic? 0 / 180 Section 2 Your health history In this section, we’d like to get an understanding of any previous health issues you have had, which might impact on your current problem. Your Childhood 0 – 18 Did you have any childhood illnesses? *YesNoUnsure Did you have any serious falls as a child? *YesNoUnsure Did you play youth sports? *YesNoUnsure Did you take / use any drugs? *YesNoUnsure Did you have any surgery? *YesNoUnsure Have you fallen / jumped from a height over three feet? (ie, crib, trees) ? *YesNoUnsure Were you involved in any car accidents as a child? *YesNoUnsure Was there any prolonged use of medicine such as antibiotics or an inhaler? *YesNoUnsure Did you suffer any other traumas (physical or emotional)? *YesNoUnsure As a child, were you under regular Chiropractic care? *YesNoUnsure Any other comments? 0 / 180 Adult 18 to present Do you / did you drink alcohol? *YesNoUnsure On average, how many units do you drink, per week? Do you / did you smoke? *YesNoUnsure On average, how many times do you smoke, per week? Have you been in any accidents? *YesNoUnsure In a few words, please outline your accident Have you had any surgery? *YesNoUnsure In a few words, please outline your surgery Do you play / have you played sports as an adult *YesNoUnsure Which sports do you participate in? Do you participate in extreme sports? *YesNoUnsure Which extreme sports do you participate in? On a scale of 1 to 10, describe your personal stress level *12345678910 On a scale of 1 – 10, describe your occupational stress level *12345678910 How is your diet? *PoorGoodExcellent How is your exercise? *PoorGoodExcellent How is your sleep? *PoorGoodExcellent How is your general health? *PoorGoodExcellent Part 3 Your current problem In this final section, let’s get the details of your current problem Your current complaint What is your main complaint, symptom or concern? *0 / 180 Are you experiencing pain? *YesNo Describe your pain SharpDullComes and goesTravelsConstant(Please tick all that apply) Since the pain began, is it…About the sameGetting betterGetting worse Does anything make the pain worse? 0 / 180 Does your pain interfere with (tick all that apply)WorkSleepWalkingSittingHobbiesLeisure Please tick all the symptoms you have experienced, even if they don't seem related to your current problemHeadachesPins and needles in armsDizzinessNumbness in fingersFatigue Sleeping problemsDiarrhoeaCold sweatsMood swingsLoss of smellBuzzing in earsNumbness in toesDepressionStiff neckConstipationLights bother eyesMenstrual painFaintingBack painRinging in earsLoss of tasteIrritability Cold handsFeverProblems urinatingMenstural irregularityNeck painLoss of balanceNervousnessStomach upsetTensionCold feet Hot flushesHeartburnUlcers Date of your last period * We require this information for saftey pruposes Is there any chance you might be pregnant? *Please select an optionYesNoWe require this information for saftey pruposes Thank you for completing the new patient intake form. You can now submit your responses for processing at Complete Chiropractic. Please check the box below to show that you have read and understood our policies and then press “submit form”. GDPR *Yes, I agree with privacy policy, terms and condition Submit form Please do not fill in this field.
