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
Have you previously received chiropractic care?
If yes, please describe:
Do you have any diagnosed medical conditions?
If yes, please list:
Are you currently taking any medications or supplements?
If yes, please list:
Have you had any recent surgeries or hospitalizations?
If yes, please describe:
Do you have any allergies (e.g., medications, foods, environmental)?
If yes, please list:
Do you have a history of any of the following? (Check all that apply)
Arthritis
Osteoporosis
Herniated discs
Scoliosis
Chronic pain
Autoimmune disorders
Neurological conditions
Cardiovascular issues
Other (please specify):
What is the primary reason for seeking chiropractic consultation?
Back pain
Neck pain
Joint pain
Headaches/migraines
Posture issues
Sports injury
Accident/whiplash
General wellness
Other (Please Specify):
How long have you been experiencing this issue?
Less than 1 week
1-4 weeks
1-6 months
Over 6 months
Rate the severity of your pain/discomfort on a scale of 1-10 (1 = mild, 10 = severe):
Are there any activities or positions that worsen your symptoms?
If yes, please describe:
Are there any activities or positions that improve your symptoms?
If yes, please describe:
Have you tried any treatments or therapies for this issue?
If yes, please describe:
What is your occupation?
Do you have a physically demanding job?
How often do you exercise?
Daily
3-5 times per week
1-2 times per week
Rarely
Do you smoke or use tobacco products?
Do you consume alcohol?
If yes, how often?
How would you describe your stress levels?
Low
Moderate
High
Do you have access to a reliable internet connection and a device for video calls?
Are you comfortable with receiving advice and guidance remotely without in-person physical adjustments?
Do you understand that online consultations may have limitations compared to in-person visits?
Are you seeking the following from this consultation? (Check all that apply)
Pain management strategies
Exercise/stretching recommendations
Posture correction advice
Lifestyle and ergonomic tips
General wellness guidance
Other (please specify):
Do you have any concerns or questions about online chiropractic consultations?
If yes, please describe:
I understand that the information provided will be used to assess my suitability for online chiropractic consultations and to provide personalized recommendations.
I acknowledge that online consultations are not a substitute for in-person medical care and that I should seek immediate medical attention if I experience severe symptoms or emergencies.
I consent to the chiropractor recording and storing my information securely in accordance with privacy laws.
Client Signature
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