Pre-Consult Form | Chiropractor North Sydney

Personal information

Full Name *

Date of Birth

Address

Home Telephone

Work Telephone

Mobile Telephone *

Email Address

Occupation *

How did you find out about us (who referred you, or what keywords did you type if you used Google)? *

Reason for attending this clinic

I am here for *

A specific concern

General health advice

Preventative care

Please describe in your own words your main concern *

If you have a specific injury or complaint, please answer the following questions, if relevant:

When did you first notice this problem? *

How did this happen, or was it for no apparent reason? *

Is your pain local only or does it refer to other parts of your body? *

Are your symptoms *

Improving

Unchanging

Worsening

What makes it worse? *

What makes it better? *

Has your sleep been disturbed as a result of this complaint? *

Yes

No

Previous diagnoses/imaging (X-ray, MRI, etc)

List any treatments in the past that have either helped or not helped with your complaint

General history

Please list any specific illnesses or health problems that family members or relatives have suffered from

Please list any accidents or trauma that you have experienced in the past, and when it occured

Please list any current/recent medications, supplements/herbals or social drugs used by you

Please list any illnesses that you currently or previously experienced, and when

Please list any surgeries or hospitalizations that you required in the past (including cosmetic)

Lifestyle

Do you exercise? *

Regularly

Irregularly

Rarely or never

Please describe your usual sport, exercise and recreational activities *

Have you ever smoked, and how much? *

How much alcohol do you drink per week? *

Diet *

Excellent

Fair

Poor

Sleep *

Excellent

Fair

Poor

Stress *

Excellent

Fair

Poor

Is there anything happening in your life right now (work/home/etc) that is concerning you?

Please list any supplements you might be taking

Have you noticed any of the following?

Visual disturbances *

No

Yes

Nausea or vomiting *

No

Yes

Chest pain or discomfort *

No

Yes

Difficulty breathing *

No

Yes

Unexpected weight loss in the last 6 months *

No

Yes

Fainting or loss of consciousness *

No

Yes

Changes to hair, skin or nail condition *

No

Yes

Decreased urinary or bowel control *

No

Yes

Fatigue unresolved with sleep *

No

Yes

Practice policy

Attend at the allocated appointment time.
Provide at least 24 hours notice if I cannot attend my appointment.
Pay a late cancellation fee in the event 24 hours notice of cancellation has not been provided (at the discretion of the practitioner)
Bring suitable clothing to the appointment (gym shorts/tights, singlet/top/sports bra). This enables the practitioner to examine your area of concern adequately.
Settle my account before I leave the practice.
Disclose any past or current illness, surgery, previous trauma, medications, drug use and any known health risks in this pre-consultation form, and agree to provide any related new information during the period of care at this practice or by practitioners who have assessed or treated me at this practice.
Be contacted via SMS/email service for appointment reminders, prescribed exercises and to receive a monthly newsletter, all of which can be unsubscribed to at any time.
Information gathered from my time in treatment at this practice being used for scientific research purposes to improve this field of healthcare. Personal details will never be disclosed in any publishable material.

Consent to care

I acknowledge the physical therapy techniques used at this practice may include spinal manipulative therapy; joint mobilisation; the McKenzie Method; soft tissue massage including Active Release Technique [ART]; nutritional advice; exercise prescription; dry needling; and/or supportive taping.
Whilst these therapies are recognised as being safe and effective interventions for people of all ages, and are well established in the history of practice, I understand as with all health care disciplines, that there is a risk of complications. These may include muscle soreness; aggravation of the condition; bone or joint injury; stroke (
<1 case in one million); sprain/strain/rupture to intervertebral disc or ligament; bruising; headache or light-headedness.
I will inform my practitioner of any particular therapy I wish not to have.
I understand my consent does not waive my Common Law Rights.
I hereby acknowledge my consent to undergo assessment and treatment at this practice and understand that I may withdraw my consent to care at any time. By adding your full name below, you acknowledge that you have carefully read all of the above information and that you understand and agree to each point that is made. You will be asked to sign a printed copy of this form when you present at the initial consultation.

Acknowledgement

By adding your full name below, you acknowledge that you have carefully read all of the above information and that you understand and agree to each point that is made.

Please sign your signature below *

Date this *

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