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Welcome to Buderim Chiropractic! We appreciate the opportunity to serve you. We ask you to assist us by completing the following questions.

Date

Full Name

Preferred Name

If you are under 18, what is your mother's name?

If you are under 18, what is your father's name?

Address

Postcode

Home phone

Mobile

Work phone

Date of Birth

Age

Occupation

Relationship Status

If in a relationship, partner's name

Names and Ages of Children

Who referred you to Buderim Chiropractic?

Have you ever received chiropractic care?

Yes

If yes, from whom?

If yes, when was your last adjustment?

Your Health History

About Your Life Journey

The human body is designed to be healthy. Throughout the course of your life's journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they have likely had an accumulating effect on your life and health. Please answer the following questions regarding your life's journey.

Pregnancy

Did your Mum and Dad...

Prepare their body for pregnancy?

Yes

Unsure

Plan and welcome the pregnancy

Yes

Unsure

Have chiropractic care during pregnancy?

Yes

Unsure

Have a nutritious diet during pregnancy?

Yes

Unsure

Exercise through pregnancy?

Yes

Unsure

Smoke or drink alcohol during pregnancy?

Yes

Unsure

Endure stress during pregnancy?

Yes

Unsure

Have any scans?

Yes

Unsure

Birth Process

Home birth?

Yes

Unsure

Hospital birth?

Yes

Unsure

Induced labour?

Yes

Unsure

Was your birth

Early

Late

On due date

Not sure

Drugs during delivery?

Yes

Unsure

Long delivery?

Yes

Unsure

Difficult delivery

Yes

Unsure

Caesarean (elective/emergency)?

Yes

Unsure

Growth and Development

Physical

Did you reach all your milestones?

Yes

Unsure

Were you taught how to care for your spine?

Yes

Unsure

Did you fall on your head?

Yes

Unsure

Were you a head-banger/rocker?

Yes

Unsure

Did you have any major accidents?

Yes

Unsure

Did you have any surgery?

Yes

Unsure

Physical abuse by siblings/other?

Yes

Unsure

Did you play childhood sports?

Yes

Unsure

Chemical

Take medication/drugs?

Yes

Unsure

Were you breast-fed?

Yes

Unsure

If so, for how long?

Yes

Unsure

If so, for how long?

Were you bottle fed?

Yes

Unsure

If so, for how long?

Vaccines received?

Yes

Unsure

Emotional

Was there any stress in the family?

Yes

Unsure

Was there a loss of a family member/relative?

Yes

Unsure

Was there communication breakdown in the household?

Yes

Unsure

If yes to any of the above, please give details

Lifestyle

Do you eat healthy foods?

Yes

Unsure

Do you smoke?

Yes

Unsure

Do you drink alcohol?

Yes

Unsure

Do you drink adequate water?

Yes

Unsure

Do you drink any caffeinated drinks?

Yes

Unsure

Are your teeth healthy?

Yes

Unsure

Do you sleep well?

Yes

Unsure

Are you physically stressed

Yes

Unsure

Are you mentally stressed?

Yes

Unsure

Are you taking or have you ever taken drugs/medication?

Yes

Unsure

Do you exercise regularly?

Yes

Unsure

Sports/Hobbies

Accidents

Drugs/Medications

Surgery

Have you experienced a loss in the past 5 years (financial, relationship, family)

Health Goals

People consult Buderim Chiropractic with one or more of the following health goals. Please indicate which apply to you.

Relief of my symptom

Correction of my underlying problems

To maximise my health

To maximise myself, my family's and my community's health

You may have specific reasons for consulting Buderim Chiropractic. If this is the case, what are they?

How would you rate your overall health, out of 10?

What would you like your health to be?

Your Health History

About Your Life Journey

Pregnancy

Birth Process

Growth and Development

Physical

Chemical

Emotional

Lifestyle

Health Goals

OUR MOTTO

chiropractic techniques

CLINIC HOURS

our location