First Name*Surname*DOB*Address*Suburb*Postcode*Mobile*WorkMarital Status*SingleMarriedDe factoWidowDivorcedEmail*Occupation*Sex*MaleFemalePrivate health insurance*Please choose of the below optionsYesNoMedicarePlease choose one of the options belowYesNoWorkcover / CTP claim?*Please choose one of the options belowYesNoClaim noDept of Veteran's AffairsPlease choose one of the options belowYesNoNo ideaGP or Medical Practice detailsHow did you hear about us?*Please choose one of the options belowWalked PastGoogleGiven a VoucherYellow PagesWord of MouthOtherIf Word of Mouth or Other, please indicate who or where. If you found us through Google please indicate the keywords you entered into the search bar. eg North Sydney Chiropractic etc*Your Presenting ProblemMajor Complaint*Date of onset*Please indicate on a score of 0 to 10, how intense the pain is. (0=no pain, 10=extreme pain)Pain RatingPlease choose one of the options below12345678910Are there any other area/s of pain not included above? Are there any other associated symptoms associated with your pain? i.e. numbness, pins and needles, headache, blurry vision etc.If you have any neck pain or headache, please indicate whether you are experiencing any of the following symptoms.DizzinessVisual loss or disturbances i.e. blurry visions, spots in eyes etc.Clumbsiness or uncoordinated movementsDifficulty speakingThrobbing or splitting headache unlike any other you have previously experiencedAll of the aboveNone of the aboveHave you ever sought any treatment for this complaint?*Please choose one of the options belowYesNoPrevious treatment i.e. Chiro, physio, osteo, massage, GP/Medical?Any other complaintsGeneral HealthAccidents (Incl car, bike, work etc)*Please choose one of the options belowYesNoDetails- when? any injuries sustained?Previous surgery (incl. breast augmentation)*Please choose one of the options belowYesNoDetails- when and what for?Medications*Please choose one of the options belowYesNoDetails- name and for what condition?Supplements*Please choose one of the options belowYesNoDetails- name and for what reason?Unexplained weight loss*Please choose one of the options belowYesNoPlease provide more details i.e. how many kgs over time.Abnormal bleeding from any body part?*Please choose one of the options belowYesNoPlease proivide more details.Recenty Changes to mole or freckles*Please choose one of the options belowYesNoPlease provide more details.Lifestyle and WellnessExercise*Please choose one of the options belowNoneIrregularRegularlyDetails- how often? what type?Sports*Please choose one of the options belowSocialCompetitiveWhich sports?Diet*Please choose one of the options belowPoorFairGoodExcellentParticulars about your diet i.e. allergies or intolerances. avoiding anything specific?Sleep*Please choose one of the options belowPoorFairGoodExcellentHow many hours per night? Quality? Dreams/Nightmares?Sleeping Position*Please choose one of the options belowSide SleeperBack SleeperFront SleeperSide and back onlyAll of the aboveStress*Please choose one of the options belowLowMediumHighlyDetails Work / Home etc?Smoking*Please choose one of the options belowYesNoHow many Cigarettes/Packs per day/week.Alcohol*Please choose one of the options belowYesNoDrinks per day/week?Any other Health Related issues? (i.e.heart problems, diabetes, hypertension, cancer, depression and anxiety, asthma, arthritis and/or osteoporosis?If you could improve anything about your health, what would be your goals?1:2:3:Treatments The practitioners at North Sydney Sports and Chiropractic may use any of the following therapies in your care: Spinal Manipulative/Adjustments Soft Tissue Mobilization Exercise Rehabilitation Nutritional therapy/advice Taping Techniques Dry Needling Techniques The therapies offered by the practitioners at North Sydney Sports and Chiropractic have a long history of practice; however as with all treatments there are some inherent risks. These include: Aggravation of an existing condition Headache Rupture to disc Sprain/Strain to disc or ligament Infection Stroke or stroke-like symptoms Relaxed or sleepy feeling Bruising or muscle soreness Sprain/strain to muscle or tendon Fracture Please tell your practitioner if you do not want a particular type of treatment. I understand the possible risks of the treatment outlined above. I give consent to the proposed care by any practitioner who operates at North Sydney Sports and Chiropractic. This consent does not waiver your Common Law Rights; rather it is merely for you to acknowledge that you have been informed of the common known risk. I understand that I can withdraw my consent to treatment at any time I give consent to my patient notes to be shared with practitioners/therapists that work within North Sydney Sports and Chiropractic and will not be used for any other purposes than the treatment of my condition and health. *I hereby acknowledge that I have read and understand the information above. I give my consent to continue with the proposed treatment.