Complete Chiropractic – New client intake form New patient intake formWelcome 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 youYour Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof.Your First Name *Your Last Name *Gender *MaleFemaleStreet Address *City *County *Post Code *Home Phone *Work PhoneEmail Address *Occpation *0 / 180Date of Birth *Marital SatusSingleMarriedDivorcedCivil partnershipWidowedPartners Prefix *Mr.Mrs.Ms.Mx.MissDr.Prof.Partners First Name *Partners Last Name *Do you have children? *YesNoNumber of ChildrenAges of children Do you have private healthcare? *YesNoName of your healthcare fund *Will you be claiming against your insurance? *YesNoDo you have a claim numer? Please enter if yes *Did someone refer you to the clinic? 0 / 180Section 2 Your health historyIn 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 Childhood0 - 18Did you have any childhood illnesses? *YesNoUnsureDid you have any serious falls as a child? *YesNoUnsureDid you play youth sports? *YesNoUnsureDid you take / use any drugs? *YesNoUnsureDid you have any surgery? *YesNoUnsureHave you fallen / jumped from a height over three feet? (ie, crib, trees) ? *YesNoUnsureWere you involved in any car accidents as a child? *YesNoUnsureWas there any prolonged use of medicine such as antibiotics or an inhaler? *YesNoUnsureDid you suffer any other traumas (physical or emotional)? *YesNoUnsureAs a child, were you under regular Chiropractic care? *YesNoUnsureAny other comments? 0 / 180Adult 18 to present Do you / did you drink alcohol? *YesNoUnsureOn average, how many units do you drink, per week? Do you / did you smoke? *YesNoUnsureOn average, how many times do you smoke, per week? Have you been in any accidents? *YesNoUnsureIn a few words, please outline your accidentHave you had any surgery? *YesNoUnsureIn a few words, please outline your surgeryDo you play / have you played sports as an adult *YesNoUnsureWhich sports do you participate in? Do you participate in extreme sports? *YesNoUnsureWhich extreme sports do you participate in? On a scale of 1 to 10, describe your personal stress level *12345678910On a scale of 1 - 10, describe your occupational stress level *12345678910How is your diet? *PoorGoodExcellentHow is your exercise? *PoorGoodExcellentHow is your sleep? *PoorGoodExcellentHow is your general health? *PoorGoodExcellentPart 3Your current problemIn this final section, let's get the details of your current problemYour current complaint What is your main complaint, symptom or concern? *0 / 180Are you experiencing pain? *YesNoDescribe your pain SharpDullComes and goesTravelsConstant(Please tick all that apply) Since the pain began, is it...About the sameGetting betterGetting worseDoes anything make the pain worse? 0 / 180Does your pain interfere with (tick all that apply)WorkSleepWalkingSittingHobbiesLeisurePlease 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 flushesHeartburnUlcersDate of your last period *We require this information for saftey pruposesIs there any chance you might be pregnant? *Please select an optionYesNoWe require this information for saftey pruposesThank 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 conditionSubmit formPlease do not fill in this field.
