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About
Our Offerings
Patient Forms
Knowledge
Common Answers
Get in Touch

Patient Forms

Select the relevant form for your needs from the options below

Pre-Consult Newborn-Child

Pre-Consult Adult

About
Knowledge
Our Offerings
Patient Forms
Common Answers
Get in Touch

About
Knowledge
Our Offerings
Patient Forms
Common Answers
Get in Touch

Pre-Consult Form
(Under 10 years)

Child's First Name

Child's Last Name

Parents / Guardians Names

Street Address

Apartment, suite, etc

Suburb

ZIP / Postal Code

Email Address

Phone

GenderMaleFemaleNon-Binary

Date of Birth

Month

Day

Year

How did you find out about us?

Has the patient been to a chiropractor before?YesNo

If so, when was their last adjustment?

The following are regarding fertility and pregnancy (if relevant) for this child:

Were there any fertility issues?YesNo

What gestational term did you/surrogate carry this child?

Did the mother smoke or drink during pregnancy?YesNo

Did the mother exercise during pregnancy?YesNo

Did the mother get diagnosed with gestational diabetes, pre eclampsia, etc during pregnancy?YesNo

Were there any physical or mental stressors during the pregnancy?YesNo

The following are regarding growth and development of the nervous system:

Did your child have any trouble latching (either sides) if breastfeeding?YesNo

Did your child roll to both sides and if so at what age?YesNo

Did your child crawl in a regular pattern and rhythm and at what age?YesNo

Did your child walk in a regular patter and rhythm and at what age?YesNo

Have you noticed any unusual variances or patterns:CulmsyUncoordinatedInability to sit stillInability to concentrateLacking social or emotional skillsBehavioral issuesBed wettingToe walkingOther

How much sleep does your child get on average per night?

How would you describe your child's eating habits?

How much if any time does your child spend on devices?

Any known allergies/intolerances?

Please list all current prescriptions, vitamins, minerals, herbs or supplements your child is taking.

Please list all your previous surgeries or hospitalisations

Please list any fractures.YesNo

Please list any conditions or diseases that have been diagnosed.

Please tell us the name of your GP or other specialist and their address.

What is the main reason for your child's visit today?

When did this start?

Please tell us where their pain / problem is located

If they have pain, does it travel or refer to another area? Or does it stay in the one spot?

Have they had this pain or similar pain before? When?

What makes this pain better? Please list

What makes this pain worse? Please list

Have you seen anyone else for this? If so, has it made any changes?

Is their pain getting worse?YesNo

Thanks for taking the time to complete this form, before you go is there anything other information you would like to share, or anything else to discuss during your child's consult?

Please do not fill in this field.

Pre-Consult Form
(10 years and above)

First Name

Last Name

Parents (if child)

Street Address

Apartment, suite, etc

Suburb

ZIP / Postal Code

Email Address

Phone

GenderMaleFemaleNon-Binary

Date of Birth

Month

Day

Year

Occupation

How did you find out about us?

Have you been to a chiropractor before?YesNo

If so, when was your last adjustment?

Please list all your current medications

Please list all your previous surgeries or hospitalisations

Have you ever broken any bones (i.e. fractures)?YesNo

If so, please list them here

Have you have ever been in a car accident?YesNo

If so, please advise when and also list any injuries sustained and treatment received

Please list any condition or illness you have previously been diagnosed with

Please tell us the name of your GP and their address

Please tell us about your family medical history, do you know of any conditions they have?

What is the main reason for your visit today?

When did this start? (how long have you had it)

Please tell us where your pain / problem is located

If you have pain, does your pain travel or refer to another area? Or does it stay in the one spot?

If it does travel, where does it go? (eg down the arm to the middle finger)

Have you had this pain or similar pain before? When?

What makes this pain worse? Please list

What makes this pain better? Please list

Are you taking medications for it? And have these worked?

Is your pain getting worse?YesNo

Has it stopped you from doing anything? (eg sitting or running)

Have you seen anyone else (other treatment) for this condition?

Thanks for taking the time to complete this form, before you go is there anything other information you would like to share, or anything else to discuss during your consult?