Adult Patient Health Questionnaire

Adult Patient Health Questionnaire
Child Patient health questionnaire
Infant 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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