Adult Patient Health Questionnaire

Confidential Patient Health Questionnaire

Before Completing this form please refer to our Privacy Policy

Personal Details

Please fill all sections

Name:

Date of Birth:


Address:


City/Town:


Email Address:


Preferred Contact Number:


Occupation:(optional)


Recommended by:(optional)


Medical Doctors Name:


Number of children:(optional):




Medical History

Please answer all questions. Ask for assistance if unsure.

Please describe your chief complaint today:
(eg Lower back pain, Pain in my left leg, Headaches etc)


Please select any of the following symtoms that best describes your pain or other sensation:

  • Throbbing
  • Shooting
  • Stabbing
  • Cramping
  • Gnawing
  • Hot-Burning
  • Aching
  • Heavy
  • Tender
  • Dull
  • Pins/Needles
  • Other

Please select to show how bad your usual pain is:

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

I have no pain

worst possible pain


In the past month have you suffered from any of the following?

Arm or leg weakness or pins and needles:

Clumsiness:

Loss of balance:

Problems with vision:

Dizziness:

Pins & Needles in the head, face or mouth:

Ringing in the ears:

Chest pain:

Difficulty swallowing:

Slurred speach:

Nausea or vomiting:

None of the above:


Do you or have you suffered from any of the following illnesses?

Osteoporosis:

Bone Infection:

Cancer:

Heart Condition:

None of the above:

High Blood Pressure:

Diabetes:

High Cholesterol:

Hardened Arteries:


Have you ever suffered from fainting
or blacking out?
Yes
No

Have you or any of your relatives suffered from stroke
or any heart disease?
Yes
No

Have you had any significant injury?
(eg. Lifting, car accident, whiplash, fall, head or
neck trauma, broken bones, etc)
Yes
No

Are you taking any prescription medication?
Please list and include any anticoalgulants, steroids
and strong analgesics.
Yes
No


Do you smoke or have you a history of smoking?
Yes
No

Do you have any connective tissue disorders?
e.g., Marfans Syndrome, Ehlers-Danlos, SLE.
Yes
No
Unsure

Is there any history of fibromuscular dysplasia
or medial cystic necrosis?
Yes
No
Unsure

Have you had x-rays in the past 5 years?
If yes, please specify body part?
Yes
No
Body part:

Have you had any previous chiropractic or physiotherapy care?
Yes
No

If yes, have you suffered from any adverse side effects to chiropractic treatment? Please describe:
Yes
No

Females only

Is there any family history of breast cancer?
Yes
No

Have you had a breast exam performed by your GP?:
Yes
No

If over 50, have you had a mammagram?:
Yes
No

Is there a possibilty of pregnancy?:
Yes
No

Please advise if any of the above information changes during the course of treatment


Please click here to read important information about your consent to procedures


By submitting this form you have read and understood our Privacy Policy and agreed to the submission of your infant's health details to Warragul Chiropractic Centre
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Contact Us

Warragul Chiropractic Centre,

154 Albert Rd
Warragul VIC 3820
info@warragulchiropracticcentre.com.au

Phone: 03-5622 1322

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  • DVA and Extended Primary Care Plans
  • All Private Health Insurance funds

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