Please enable JavaScript in your browser to complete this form.PATIENT DETAILS - Step 1 of 5Name *FirstLastPreferred NameI. D. / Passport Number* Non-SA Citizens - Passport Number RequiredAgeOccupationEmail *CONTACT INFORMATIONPhoneAddress (Residential or Postal)MEDICAL AID DETAILSMedical Aid NameMedical Aid NumberMain Member NameMain Member IDHow Did You Hear About The Clinic *Please SelectReferralGoogleSocial MediaOtherPlease can you indicate who referred you Informed ConsentSignatureClear SignatureDateNextParagraph TextParagraph TextParagraph TextName *FirstLastSignatureClear SignatureDatePreviousNext1. Main Complaint / SymptomsPlease SelectNeckMidbackLower backHeadachesShouldersHipsKneesAnkleWhere is the main area of pain or discomfort?Other Complaints (multiple selections possible)Please SelectNeckMidbackLower backHeadachesShouldersHipsKneesAnklesAre there any secondary complaints 3. DurationDaysWeeksMonthsYears4. 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)Dull / AcheSharp / StabbingNumbness / TinglingBurningThrobbing / Muscle AchePins & NeedlesRadiating (down arm or leg)OtherWhat does the pain feel like to you?Other:Please describe your pain in your own words6. Character of PainPlease SelectConstantIntermittent (On & Off) (Comes & Goes)Is the pain constant or does it come and go?Please describe when you experience the pain?Next7. Cause (multiple selections possible) Slip or fallLifting an object / Bending forwardMotor vehicle accidentWoke up with pain after sleepingUnknownTraumaOtherWhat caused the pain to start?Please Describe the Cause of your Pain8. Aggravating Factors (multiple selections possible)Sitting downBending forwardStanding up from sitting downPronlonged standingCoughing or sneezingLying down flat on backOtherWhat makes the pain worse?If Other, Please Describe:9. Relieving Factors (multiple selections possible)RestHeat PackIce PackPain MedicationLying DownStanding UpSittingWalkingOtherWhat makes the pain better or decrease?If Other, Please Describe:10. Past Treatment (multiple selections possible)ChiropracticPhysiotherapyMasssageGeneral PractitionerSpecialist ConsultOtherHave you received any previous treatment for this condition or pain?If Other, Please Describe:11. Previous Investigations (multiple selections possible)X-raysMRIsCT / Cat ScansUltrasoundBlood TestsHave you had any of the following investigations for the condition?If Yes, Please Specify When?12. Other Symptoms (Multiple selections possible)DizzinessNauseaVomitingBlurred VisionLoss of ConsciousnessBowel Dysfunction (inability to pass stools)Bladder Dysfunction (inability to urinate)Numbness around groin / buttocksOtherPlease specify any additional symptoms you may have had previously or currentlyIf Other, Please Describe:13. MedicationPlease list current medications (Name, Amounts, Frequency, Length of Use, Reason For Use)Next14. Sleep: Please Rate Your Sleep BelowSleep QualityGoodAveragePoorSleep PositionSideBackTummyOtherSleep Hours Per NightHas This Condition Affected Your SleepYesNo15. Stress Selected Value: 0 Rate Your Current Level of Stress? (0 to 10 scale)List The Cause/s of Your Stress? If Applicable16. Energy Levels: Selected Value: 0 How Would You Rate Your Energy Levels? (0 to 10 scale)17. List Exercise and HobbiesExercise / Hobbies:Frequency: (Per Week / Month)Time: (Minutes / Hours)18. Work Activities (multiple selections possible)Sitting at DeskThird ChoicePlease Tick Which Activities Are Most Related To Your Work:19. Medical HistoryPlease 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:Heart AttackStrokeHigh Blood PressureHigh CholesterolMultiple selections possible21. Have you had any Previous Trauma / Fractures / Car Accidents:List & Date22. Have you had any Previous Surgery:List & DateDurationFirst ChoiceSecond ChoiceThird ChoiceNumber Slider Selected Value: 0 Paragraph TextSubmit