New Patient Melissa Questionnaire

Melissa's Intake Form

Dr Melissa Car

Family Chiropractor

Welcome! Please fill in this form to the best of your ability.

Patient's details

First Name

Last Name

Date of birth

Your Address

Address Line 1

Address Line 2

City

State

Postcode

If a child, Parent/Guardian Name(s)

Phone Number

Private Health Cover

Email Address

Occupation

Emergency Contact (name and number)

How did you hear about us?

Please give more detail on your selection

Health Concerns

Please list your concerns according to their severity. When did it start? What would you rate each concern out of 10 (1 = mild, 10 = worst imaginable)? Please describe how this complaint began (if known).

Is the complaint getting:

Have you received other treatment for this current complaint?

Are you currently experiencing any sensation-change or weakness in your upper or lower extremities?

Health History

List any surgeries, trauma (eg car accident), falls, broken bones you have ever had

List all medications, supplements and/or vitamins you are currently taking:

Do you play any sport? Exercise?

Do you have any children?

Yes

Do you smoke?

Yes

Do you drink alcohol?

Do you take recreational drugs?

Yes

Do you drink caffeine?

List any health-related condition you have or do suffer from

Does any of your family (i.e. siblings, parents) suffer from: heart, lung or circulatory problems, cancer, diabetes, arthritis

Other Systems Review

Are you suffering from any stress? Work/Family/Relationships/Financial/Self-esteem etc?.

What is the outcome you’re hoping for from visiting our practice? Why?

What, if anything, has been holding you back from changing your current situation for the better?

CONSENT TO CHIROPRACTIC CARE

Please read prior to your consultation. This will be discussed further during your initial visit.

We will conduct a thorough history and examination to ensure the safety of your care.

Chiropractic care is recognised as being an effective and safe method of care for many conditions. However, you must recognise that there are risks associated with all health care procedures which you should be informed about. Please read the following carefully:

1. I acknowledge that I have discussed with Dr M. Car the rare risks associated with my proposed care which include although are not limited to muscle and joint soreness or strains, nausea and dizziness, fractures, disc injuries, strokes (or like episodes) and an exacerbation and/or aggravation of my underlying condition.

2. I also acknowledge the following additional potential risks insofar as my proposed care is concerned have been explained to me (to be discussed during your initial consultation).

3. I have had the opportunity to discuss the proposed care with Dr M. Car I also acknowledge that I have had the opportunity to ask questions about the nature, extent and purpose of the proposed chiropractic care and that I have been given sufficient time to make a decision giving consent for the care to proceed.

4. I acknowledge that I am aware of and understand the potential risks. I appreciate that results are not guaranteed.

5. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.

6. I hereby acknowledge my consent to the performance of the proposed chiropractic care by: Dr M. Car and/or any other chiropractor working in this clinic. I understand that I can withdraw consent at any time.

I have read the above and agree to discuss any concerns with Dr Melissa Car during my consultation and prior to treatment.

Patient's Name

Date

Signature

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