Gallery – Dainfern Chiro

PATIENT DETAILS - Step 1 of 5

Name *

First

Last

Preferred Name

I. D. / Passport Number

* Non-SA Citizens - Passport Number Required

Age

Occupation

Email *

CONTACT INFORMATION

Phone

Address (Residential or Postal)

MEDICAL AID DETAILS

Medical Aid Name

Medical Aid Number

Main Member Name

Main Member ID

How Did You Hear About The Clinic *

Please can you indicate who referred you

Informed Consent

Signature

Date

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Name *

First

Last

Signature

Date

1. Main Complaint / Symptoms

Where is the main area of pain or discomfort?

Other Complaints (multiple selections possible)

Are there any secondary complaints

3. Duration

Days

Weeks

Months

Years

4. Pain Level Rating

Scale 1 to 10 (Where 1 is least pain and 10 is maximum pain)

At its best:

Selected Value: 1

At its worst

Selected Value: 1

Current level

Selected Value: 1

5. Type of pain (multiple selections possible)

What does the pain feel like to you?

Other:

Please describe your pain in your own words

6. Character of Pain

Is the pain constant or does it come and go?

Please describe when you experience the pain?

7. Cause (multiple selections possible)

What caused the pain to start?

Please Describe the Cause of your Pain

8. Aggravating Factors (multiple selections possible)

What makes the pain worse?

If Other, Please Describe:

9. Relieving Factors (multiple selections possible)

What makes the pain better or decrease?

If Other, Please Describe:

10. Past Treatment (multiple selections possible)

Have you received any previous treatment for this condition or pain?

If Other, Please Describe:

11. Previous Investigations (multiple selections possible)

Have you had any of the following investigations for the condition?

If Yes, Please Specify When?

12. Other Symptoms (Multiple selections possible)

Please specify any additional symptoms you may have had previously or currently

If Other, Please Describe:

13. Medication

Please list current medications (Name, Amounts, Frequency, Length of Use, Reason For Use)

14. Sleep: Please Rate Your Sleep Below

Sleep Quality

Sleep Position

Sleep Hours Per Night

Has This Condition Affected Your Sleep

15. Stress

Selected Value: 0

Rate Your Current Level of Stress? (0 to 10 scale)

List The Cause/s of Your Stress? If Applicable

16. Energy Levels:

Selected Value: 0

How Would You Rate Your Energy Levels? (0 to 10 scale)

17. List Exercise and Hobbies

Exercise / Hobbies:

Frequency: (Per Week / Month)

Time: (Minutes / Hours)

18. Work Activities (multiple selections possible)

Please Tick Which Activities Are Most Related To Your Work:

19. Medical History

Please indicate any medical conditions which you currently have or have had?

20. Please Select If You Have Or Have Had Any of The Following Conditions:

Multiple selections possible

21. Have you had any Previous Trauma / Fractures / Car Accidents:

List & Date

22. Have you had any Previous Surgery:

List & Date

Duration

First Choice
Second Choice
Third Choice

Number Slider

Selected Value: 0

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