INITIAL CONSULTATION FORM Initial Consultation FormWelcome 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 Email Occupation Relationship Status If in a relationship, partner's name Names and Ages of Children How did you hear about us? Facebook Instagram Website Google LocationWho referred you to Buderim Chiropractic? Have you ever received chiropractic care? Yes NoIf yes, from whom? If yes, when was your last adjustment? Your Health HistoryAbout 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 No UnsurePlan and welcome the pregnancy Yes No UnsureHave chiropractic care during pregnancy? Yes No UnsureHave a nutritious diet during pregnancy? Yes No UnsureExercise through pregnancy? Yes No UnsureSmoke or drink alcohol during pregnancy? Yes No UnsureEndure stress during pregnancy? Yes No UnsureHave any scans? Yes No UnsureBirth ProcessHome birth? Yes No UnsureHospital birth? Yes No UnsureInduced labour? Yes No UnsureWas your birth Early Late On due date Not sureDrugs during delivery? Yes No UnsureLong delivery? Yes No UnsureDifficult delivery Yes No UnsureCaesarean (elective/emergency)? Yes No Unsure Growth and Development PhysicalDid you reach all your milestones? Yes No UnsureWere you taught how to care for your spine? Yes No UnsureDid you fall on your head? Yes No UnsureWere you a head-banger/rocker? Yes No UnsureDid you have any major accidents? Yes No UnsureDid you have any surgery? Yes No UnsurePhysical abuse by siblings/other? Yes No UnsureDid you play childhood sports? Yes No UnsureChemicalTake medication/drugs? Yes No UnsureWere you breast-fed? Yes No UnsureIf so, for how long? Yes No UnsureIf so, for how long? first 3 monthsfirst 3 monthsfirst 6 monthsfirst 9 monthsup to about one yearmore than one yearWere you bottle fed? Yes No UnsureIf so, for how long? first 3 monthsfirst 3 monthsfirst 6 monthsfirst 9 monthsup to about one yearmore than one yearVaccines received? Yes No UnsureEmotionalWas there any stress in the family? Yes No UnsureWas there a loss of a family member/relative? Yes No UnsureWas there communication breakdown in the household? Yes No UnsureIf yes to any of the above, please give details LifestyleDo you eat healthy foods? Yes No UnsureDo you smoke? Yes No UnsureDo you drink alcohol? Yes No UnsureDo you drink adequate water? Yes No UnsureDo you drink any caffeinated drinks? Yes No UnsureAre your teeth healthy? Yes No UnsureDo you sleep well? Yes No UnsureAre you physically stressed Yes No UnsureAre you mentally stressed? Yes No UnsureAre you taking or have you ever taken drugs/medication? Yes No UnsureDo you exercise regularly? Yes No UnsureSports/Hobbies Accidents Drugs/Medications Surgery Have you experienced a loss in the past 5 years (financial, relationship, family) Health GoalsPeople 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 healthYou 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? Please select12345678910What would you like your health to be? Please select12345678910Submit Form
