NEW LAMBTON FAMILY

C H I R O P R A C T I C

Practice Member Details

CONFIDENTIAL

NAME: Mr/Mrs/Ms______

ADDRESS: ______

______POSTCODE: ______

PHONE WORK: ______PHONE HOME: ______

MOBILE NO.______E-MAIL______

BIRTHDATE: ______OCCUPATION: ______

MARITIAL STATUS______NO. OF CHILDREN: ______

PARTNER’S NAME: ______NAMES/AGES OF CHILDREN ______

What Health fund do you belong to ______

Does it cover Chiropractic care? Yes____ No ____

I was recommended to come to this center by:

____ Friend or Family (please name)______

____ NEWCASTLE Yellow Pages____ Community Talk____ Sign (out the front)

____ Health Care Class____ Displays/Screenings____ Another Chiropractic Center

____ Newspaper Ad____Other

……………………………………………………………………………………………………………

OFFICE USE ONLY: DATE OF REPORT: ______

QUALITY CARE FOR NEWCASTLE FAMILIES

Give reason for seeking Chiropractic care: ______

______

How long have you had this problem? ______

When this problem is at its worst, can you explain in your own words how exactly it feels? _____

______

______

Before you began to suffer with this problem, was there an earlier accident injury or condition that may or may not have been related to this problem? (Example: fall, injury, work injury, sports trauma, repetitive motion on the job) ______

Family history of same or similar problem. If so give details. ______

______

Are you under the care of any other physician? Yes____ No ____

If yes, please list the doctors you are seeing, condition you are treated for, and progress of care to date. ______

______

Please list any medications you are presently taking and reason for taking it. ______

______

Please list all previous surgeries. ______

List any X-rays you have had in the last two years. ______

Have you been to a Chiropractor before? Yes _____No ______

Date of last visit? ______How long were you under care? ______

Condition treated for? ______Name of Chiropractor ______

What activity does this problem prevent you from doing, either partially or totally, that you would really like to be doing again? ______

How does this problem prevent you from doing that? ______

On a scale of 1 – 10, ten being the highest, rate your commitment to getting rid of the problem. ______