PATIENT HISTORY First Name *Last Name *Date *Address *Address Line 1Address Line 2CityState / Province / RegionZip / Postal CodeAustraliaCountryMobile number *Email *Date of birth Occupation Marital status MarriedSingleWidowedDivorcedDe factoNo. of children Are you pregnant? *YesNoSports/Interests How did you hear about us? (eg Google, name of friend, walking past, etc) Emergency contact’s name and mobile numberFirst Name Last Name Phone Health ConcernsPlease list your health concerns according to their severity Rate severity 1 = mild 10 = worst imaginable When did this episode start? If you had this condition before, when? % of the time pain is present Please list any additional health concerns according to their severity Rate severity 1 = mild 10 = worst imaginable When did this episode start? If you had this condition before, when? % of the time pain is present Is the condition getting progressively worse? YesNoConstantComes and goesIs this condition interfering with your? WorkSleepDaily routineSports/exerciseOtherWhich activities aggravate your condition? What relieves this condition? I do (do not) have a family history of this or similar symptoms Other Doctors seen for this condition ChiroGPPhysioOtherWhat did they say was wrong? General Health HistoryHave you had any surgery? (Please include all surgeries and when you had them done) Have you had any accidents and/or injuries eg. car accident, work-related, etc? (Especially those related to your present problems. Please include when these accidents happened). Do you wear orthotics or heel lifts? YesNoCurrent Medicine/Supplements Functional Rating Index For use with Neck and/or Back Problems only. In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please tick the box which most closely describes your condition right now.Pain Intensity 0 - No pain1 - Mild pain2 - Moderate pain3 - Severe pain4 - Worst possible painSleeping 0 - Perfect sleep1 - Mildly disturbed sleep2 - Moderately disturbed sleep3 - Greatly disturbed sleep4 - Totally disturbed sleepPersonal Care (washing, dressing, etc.) 0 - No pain; no restrictions1 - Mild pain: no restrictions2 - Moderate pain; need to go slowly3 - Moderate pain; need some assistance4 - Severe pain; need 100% assistanceTravel (driving, etc.) 0 - No pain on long trips1 - Mild pain on long trips2 - Moderate pain on long trips3 - Moderate pain on short trips4 - Severe pain on short tripsWork 0 - Can do usual work plus unlimited extra work1 - Can do usual work; no extra work2 - Can do 50% of usual work3 - Can do 25% of usual work4 - Cannot workRecreation 0 - Can do all activities1 - Can do most activities2 - Can do some activities3 - Can do a few activities4 - Cannot do any activitiesFrequency of pain 0 - No pain1 - Occasional pain; 25% of the day2 - Intermittent pain; 50% of the day3 - Frequent pain; 75% of the day4 - Constant pain; 100% of the dayLifting 0 - No pain with heavy weight1 - Increased pain with heavy weight2 - Increased pain with moderate weight3 - Increased pain with light weight4 - Increased pain with any weightWalking 0 - No pain; any distance1 - Increased pain after 1 mile2 - Increased pain after 1/2 mile3 - Increased pain after 1/4 mile4 - Increased pain with all walkingStanding 0 - No pain after several hours1 - Increased after several hours pain2 - Increased pain after 1 hour3 - Increased pain after 1/2 hour4 - Increased pain with any standing Past Health History – Please tick any boxes that apply to YOUR healthHead HeadacheSinusBack of head painForehead painTemple painMigraineLight-headednessFaintingBlurred visionDouble VisionLoss of tasteLoss of balanceDizzinessRinging in earsLoss of hearingPain in earsJaw pain/clickingArms & Hands (copy) Pain in upper armPain in elbowMovement aggravatedTennis elbowPain in forearmPain in handsPain in fingersPins & Needles in armsP & N in fingersNumbness in arms/fingersHands coldSwollen joints in fingersSore joints in fingersArthritis in fingersLoss of grip strengthHips, Legs & Feet Pain in buttocks R/LPain in hip joint R/LPain down leg R/LPain down both legsKnee pain R/LInsideOutsideLeg crampsCramps in feetPins & needles in legs R/LNumbness of legs R/LNumbness of feet R/LCold FeetSwollen anklesChest Chest painShortness of breathAsthmaBreast painDimpled or orange-peel breastIrregular heart beatIndigestion/heart burnNeck Pain in neckPain on movementMuscle spasms in neckForehead painGrinding/popping sounds in neckShoulders Pain in shoulder R/LPain across shouldersArthritis R/LCan’t raise arm above shoulderCan’t raise arm OverheadTension in shouldersAbdomen Nervous stomachFoods can’t eatNauseaWindConstipationDiarrhoeaHaemorrhoidsMid-Back Mid-back painPain between shoulder bladesPain in kidney areaLow-Back Low-back painSacroiliac painMuscle spasmsArthritisGeneral NervousnessIrritableDepressedFatigueGenerally run-downLoss of weightWeight gainDiabetesNormal hours of sleep: Lost hours of sleep: Allergies: Coffee/Tea cups per day: Cigarettes per day: Women Only (copy) CrampingIrregularityHysterectomyDischargeTumoursMenopausalPost-menopausalMen Only (copy) Urinary frequencyDifficulty in startingNight urinationProstate symptomsPlease tick the areas of complaint HeadJawsShouldersElbowsWristsPelvisKneesAnklesOther information CommentSubmit
