Patient Informations

Patient Form

PATIENT INFORMATION

Sex
Marital Status

IN CASE OF EMERGENCY, CONTACT

HOW CAN WE HELP YOU?

How bad is it? How intense are your symptoms? (circle)

Please circle areas to the right where you have pain or other symptoms:

What does it feel like? (check where appropriate)

IMPACT OF YOUR SYMPTOMS

How is this symptom / condition interfering with your life? (check where appropriate)

Work
Exercise
Recreation
Sleep
Self-Care
Energy
Attitude
Patience
Productivity
Creativity
Other
How committed are you to correcting this issue?

PATIENT WELLNESS ASSESSMENT

On the arrow diagram above:

What are your health goals?

CHILDREN & PREGNANCY

Are you currently pregnant?

HEALTH & ILLNESS HISTORY

Checkboxes

ALLERGIES, MEDICATIONS & SUPPLEMENTS

HISTORY OF TRAUMA

CHIEF COMPLAINT

When Did It Start?
What is the pain like?

NOTES ON LIFE EFFECT

Are you a smoker?
If we could help you improve areas of your life, which would they be?

IF YOU HAVE HAD CHIROPRACTIC CARE BEFORE, PLEASE COMPLETE THE FOLLOWING

PATIENT INFORMATION - INFORMED CONSENT

Chiropractic is one of the most widely used drug free health care professions in the world. For your own awareness we have chosen to inform you
of very unlikely but possible risks associated with chiropractic.

  • Very rare risks may include post adjustment muscle soreness, strain to a ligament or disc in the neck/lower back, and possible
    aggravation of underlying conditions.
  • Extremely rare is the risk of damage to neck blood vessels which can arise in a stroke or stroke- like symptoms.

Chiropractic adjustments of the spine are internationally recognised as being far safer statistically than medication and other alternatives. If you
have any questions relating to the care you are about to receive, please speak to your chiropractor.

I acknowledge the above information and do not expect the chiropractor to be able to anticipate all potential risks and complications. Based on the
information provided, I consent to and look forward to receiving chiropractic care in this office, if required.

Maximum file size: 33.55MB

Risk Ratios & Statistics: Cervical Spine

(Neck)

-(Temporary) Radiculopathy associated with disc injury -1:139,000 

-Vascular injury  -1:5.85 million 

Lumbar Spine

-Disc injury with radiating pain    1:62,000 

-Radiculopathy    1:188,000

-Cauda Equina syndrome  1:565,000

In comparison

Hospitalisation for gastro intestinal bleeding (NSAID) (following 1 month of medication)   1:250 

-Deaths associated with NSAIDS (US) 3200pa (AUST)  360 pa

-Deaths from general anaesthetic  1:1250

-Injury from motor vehicle accidents  1:9300 

-Hospitalisation from adverse drug reactions  20,000 – 26,000 pa

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