Funnell Family Chiropractic - Entrance Form printable pdf download

FUNNELL FAMILY CHIROPRACTIC - ENTRANCE FORM

Dear New Patient,

It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. To help us serve you better,

please complete the following information. We look forward to working with you to build better health for you and

your family.

Today’s Date: ______ / ______ / ______

Name: Mr. / Mrs. / Miss / Ms______________________________________________________________________

I prefer to be called: ___________________________ Date of Birth: _______ / ______ / ______ Age: ___________

Phone: Home ____________________ Business _____________________Mobile __________________________

E-mail Address: _______________________________________________________________________________

Postal Address: _______________________________________________________________________________

Occupation: _______________________________Employer:___________________________________________

Are you: Married /single /Widowed /Divorced /Defacto

Spouse/Partner’s Name: ___________________________

Do you have any children? ___________ How many? ________ What ages are they? _______________________

Who or what referred you to us? __________________________________________________________________

Is this an ACC claim?

Yes / No

Have you had any spinal x-rays taken in the past 2 years? Dates _________________________________________

Who was your last Chiropractor? __________________________________________________________________

When did you last visit the Chiropractor? Date ______ / ______ / ______

Who is your Medical Doctor? _____________________________________________________________________

Please state the reason for your visit to us today: _____________________________________________________

_____________________________________________________________________________________________

Your health today is often the result of various physical stresses, chemical stresses and emotional / mental stresses

from which your body has not fully recovered. The following questions will help your chiropractor assess your current

health status and determine the most appropriate care plan for you.

PHYSICAL STRESS:

- Have you experienced any of the following?

Broken bones? If so, which bones? ________________________________________________________________

Operations or surgery of any kind? ________________________________________________________________

Have you ever been knocked unconscious? _________________________________________________________

What accidents have you had during your life that you can remember? (Please include minor falls, hitting head,

minor car accidents, etc.) ________________________________________________________________________

_____________________________________________________________________________________________

What sports / recreation do you participate in? _______________________________________________________

Funnell Family Chiropractic - Entrance Form