George Street Chiropractic
East Fremantle

GSCQuestionnaire

 

Clinic Questionnaire

The initial intake form is important because many health problems can mimic disorders of the spine. This establishes your health background, for things such as surgeries, accidents, the onset of your immediate condition, and other details affecting current health. Examining your history also helps the chiropractor determine whether the immediate reasons for your consult is, in fact, spine-related.

Please fill out all information to the best of your ability and note patients who have reservations about ticking any questions may discuss these with the Chiropractor personally. 

All case histories are treated with absolute confidentiality.

PERSONAL INFORMATION
Title
Name *
Name
Address
Address
If you do not have a regular GP - Who did you see last. If you don't have one - tick "I don't have one"
We need to know this as some health funds require specific item numbers
Are you covered for chiropractic care?
We are grateful that our practice grows by referral.
Have you ever seen a chiropractor before?
Major complaint
Please outline your main ailments that brought you here today
Was there any of the following prior to or during the onset?
Please specify if you ticked 'Other significant event'
Is the problem getting worse?
Medical History & General Health
This is important because many health problems can mimic disorders of the spine. This establishes your health background, for things such as surgeries, accidents, the onset of your immediate condition, and other details affecting current health. Examining your history also helps the chiropractor determine whether the immediate reasons for your consult is, in fact, spine-related.
Current health
Please tick all appropriate boxes if you:
Have you been hospitalised or had any form of surgery?
If you have had surgery, please fill out any form of surgeries or hospitalisations you have had and what year they were
Are you currently taking any form of medication?
If yes, please list them all and for what purpose
Are you currently taking any form of supplements or vitamins?
If yes, please list them all and for what purpose
Have you had any broken bones, bad falls, accidents or dislocations?
If yes, please specify
past and current ailments
Please tick all relevant illnesses that you are currently, or have suffered from in the past - if there are no issues, tick 'None of the above'
Cardiovascular
if you ticked other, please specify
Female Reproductive
For females only
if you ticked other, please specify
Male Reproductive
For males only
if you ticked other, please specify
Musculoskeletal
if you ticked other, please specify
Digestive
if you ticked other, please specify
Urinary
if you ticked other, please specify
Respiratory
if you ticked other, please specify
Eyes, Ears, Nose & Throat
if you ticked other, please specify
Other Health Problems
if you ticked other, please specify
General emotional issues
tick any cause of stress, tension and/or anxiety that may afflict you - if there are no issues, tick 'None of the above'
if you ticked other, please specify
Medical correspondence and referral
Do you give consent for your clinical information to be communicated to your general practitioner or preferred health practitioner? *
Our practice specialises in treating problems of the spine and associated disorders of the nervous system. A proportion of our patients come via referral from their medical practitioner. As such, it is standard practice to correspond with your medical practitioner where appropriate.
If under 18, name of parent or legal guardian
If under 18, name of parent or legal guardian