Funnell Family Chiropractic - Entrance Form (Page 2 of 2) in pdf

Do you know if you had a traumatic birth when you were born? E.g. forceps, vacuum extraction, breech, induced,

caesarian, prolonged etc_________________________________________________________________________

_____________________________________________________________________________________________

Workplace activities: which of the following applies to you? Please tick:

Prolonged sitting

Keyboard use

Heavy machinery operation

Heavy /prolonged lifting

Driving

Other physically demanding tasks

___________________________________________

CHEMICAL STRESS:

Are you a smoker? Yes / No

If so, for how long? ____________________________________________

Alcohol consumption?

None / Occasionally / Often

Have you been exposed to smoke, fumes or chemicals on a prolonged basis?

(Garden or farm sprays, work chemicals etc)

Yes / No

Have you been vaccinated?

Yes / No

Are you taking medications? If so, please list the drug(s) and the reason for its use if known___________________

____________________________________________________________________________________________

Nutrition – how healthy do you consider your diet? (Circle)

Unhealthy

5 Healthy

EMOTIONAL / MENTAL STRESS:

Please tick the appropriate box

None

Minor

Moderate

Significant

Work stress

Family stress

Loss of loved one

Change of relationship

Other

Do you feel that you are getting enough sleep? (Circle)

Yes / No

Do you feel that you are getting enough rest and recreation (Circle)

Yes / No

Have you had or do you have any health problems? Please explain. ______________________________________

_____________________________________________________________________________________________

Have you ever suffered from any of the following? Heart trouble / Stroke / Dizziness / Passing out

Do you have a preferred appointment time? If yes, when? ______________________________________________

I hereby authorize this office and its Chiropractors to provide me with the chiropractic care as they deem

necessary. I clearly understand and agree that I am personally responsible for payment of all fees

charged by this office.

Name: ______________________________________________________________________________

Signed:__________________________________________Date:_______________________________

Thank you for taking the time to complete this form.

Please ensure your mobile phone is switched off.

As a part of your initial chiropractic care, you will be scheduled for a report visit (where you will

receive your first chiropractic adjustment) and a chiropractic workshop (where we will explain how

you can get the most from your chiropractic care). There is no charge for the workshop

and we encourage you to bring your spouse or a friend to this visit.

We look forward to providing you with wellness chiropractic care.

Funnell Family Chiropractic - Entrance Form Page 2

Related Articles

Related forms

Related Categories