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:
Please select to show how bad your usual pain is:
I have no pain
worst possible pain
In the past month have you suffered from any of the following?
Do you or have you suffered from any of the following illnesses?
Have you ever suffered from fainting
or blacking out?
Have you or any of your relatives suffered from stroke
or any heart disease?
Have you had any significant injury?
(eg. Lifting, car accident, whiplash, fall, head or
neck trauma, broken bones, etc)
Are you taking any prescription medication?
Please list and include any anticoalgulants, steroids
and strong analgesics.
Do you smoke or have you a history of smoking?
Do you have any connective tissue disorders?
e.g., Marfans Syndrome, Ehlers-Danlos, SLE.
Is there any history of fibromuscular dysplasia
or medial cystic necrosis?
Have you had x-rays in the past 5 years?
If yes, please specify body part?
Have you had any previous chiropractic or physiotherapy care?
If yes, have you suffered from any adverse side effects to chiropractic treatment? Please describe:
Is there any family history of breast cancer?
Have you had a breast exam performed by your GP?:
If over 50, have you had a mammagram?:
Is there a possibilty of pregnancy?:
Please advise if any of the above information changes during the course of treatment
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