First Name
Last Name
Date of Birth
Gender
Email Address
Phone Number
Street Address
City/Suburb
State/Province
Postal/Zip Code
Preferred Method of Communication
Primary Reason for Seeking Online Chiropractic Consultation:
Please describe your current symptoms or concerns:
When did your symptoms begin?
Rate your current pain level (if applicable) on a scale of 0-10 (0 = No Pain, 10 = Worst Pain Imaginable):
Have you received chiropractic care before?
If yes, please provide details (including dates and provider, if possible):
Do you have any of the following medical conditions? (Check all that apply)
Recent Fractures
Severe Osteoporosis
Active Cancer
Neurological Conditions (e.g., Multiple Sclerosis, Parkinson's Disease)
Cardiovascular Conditions (e.g., Heart Disease, High Blood Pressure)
Recent Surgery
Bleeding Disorders
Infections
Inflammatory Conditions (e.g., Rheumatoid Arthritis)
Pregnancy (If applicable)
Other (Please Specify):
List any medications you are currently taking (including over-the-counter medications and supplements):
List any allergies you have:
Have you had any recent imaging (X-rays, MRI, CT scans)?
If yes, please provide details (including dates and reports, if possible):
Please select the topics you would like to discuss during your online consultation: (Check all that apply)
Posture Assessment and Correction
Ergonomic Assessment of Workspace
Exercise and Stretching Recommendations
Pain Management Strategies
Lifestyle and Wellness Advice
Injury Prevention
Education on Spinal Health
Review of Existing Medical Reports/Imaging (If applicable)
Other (Please Specify):
Are you experiencing any of the following? (Check all that apply)
Severe, debilitating pain
Loss of bowel or bladder control
Progressive neurological symptoms (e.g., numbness, tingling, weakness)
Recent traumatic injury
Unexplained weight loss
Fever with pain
Severe headaches
No symptoms. I am inquiring about preventative care.
Other (Please Specify):
Please explain why you believe an online consultation is suitable for your needs:
Do you have access to a stable internet connection and a device with a camera and microphone for video consultations?
Do you have a space where you can perform basic movements and exercises during the consultation?
Are you aware that online consultations are not a substitute for in-person examinations and treatments in all cases?
Are you aware that some conditions are not suitable for online consultation, and may require an in person visit?
Are you aware that if during the online consultation, the Chiropractor feels that an in person visit is required, they will recommend that you seek one?
I understand that online consultations are for educational and advisory purposes and may not be appropriate for all conditions.
I understand that the chiropractor will make a determination of suitability for online consultation based on the provided information.
I understand that all information shared during the consultation will be kept confidential in accordance with privacy laws.
I consent to the online consultation and agree to provide accurate and complete information.
Signature
To configure an element, select it on the form.