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Patient Intake information
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Email
*
Your email
First & Last Name
*
Your answer
Street Address & Town/City
*
Your answer
Post code:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Mobile Number
*
Your answer
If you have private medical insurance (eg Bupa or AXA) please provide details of membership number/policy number and/or authorization code;
Your answer
Height & Weight
Your answer
Biological Sex
*
Choose
Male
Female
Prefer not to say
Occupation/Job
Your answer
General Practitioner &/or Surgery Name
Your answer
Emergency contact name & mobile number:
*
Your answer
How did you hear about Sterling Spinal Wellness?
*
Google
Social Media
Referral
Promotional Event
Website
Family/Friend
Other
Required
What type of therapy are you interested in?
Chiropractic/Osteopathic care
Deep Tissue/Sports Massage
Strength and conditioning
Counselling
Accupuncture
Non-Surgical Spinal Decompression
Not sure, let the therapist decide
Areas that you experience pain/discomfort?
*
Head
Neck
Jaw
Shoulder
Elbow
Wrist
Hand
Chest
Midback
Lower back
Hips
Knee
Ankle
Foot
Other:
Required
How long has this problem persisted?
Choose
Less than 1 week
Less than 1 month
3-6 Months
1-5 Years
5+ years
10-20 years
HOW did the problem occur?
Slip/Trip/Fall
Accident
Repetative strain
Surgery
Unknown
Other:
Rate your average PAIN; 0 = none 10 = extreme
None
0
1
2
3
4
5
6
7
8
9
10
Extreme
Clear selection
Do you feel you are;
Choose
Getting better
Getting worse
No Change
How OFTEN does the pain occur?
Choose
Constant
Sometimes
Comes and goes
With activity
Which side of the body is affected
Left side
Right side
Both sides
Central
Does the discomfort;
Stay localized in one area
Radiate or travel to other areas
Other
How would you DESCRIBE the pain?
Dull ache
Throb
Sharp
Shooting
Stab
Burn
Numb/tingling
Weak
Other:
WHEN are your symptoms worse?
Morning
Afternoon
Evening
At night
Same all day long
What actions/motions/positions make the pain WORSE?
Sit
Stand
Walk
Squat
Push
Pull
Bend
Lift
Stairs
Turn head
Other:
What makes the pain BETTER?
Nothing
Rest
Heat
Ice
Medications
Stretch/Movement/Exercise
Other:
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