Personal Health History Form

Thank you for making your booking. It is now time for us to learn more about you. Please complete the following form so that we can get a better picture about how you are feeling and what else you are dealing with in your life.

We have several chiropractors at Straight Up Health. You may see only one of us or you may get a chance to see several, depending on the type or level of care you require. We each have different techniques that may help you heal. Please enjoy your journey and communicate with us.

We love children and will help you with them while you are having your appointment, if needed. Please monitor your children’s behaviour while they are here and be considerate towards other people in the waiting room. We have a change table in the toilet area for your convenience.

If we are running behind it is not because we do not care, it is usually because we care too much. Someone might be having a rough day or be in a large amount of pain and may need a bit of extra time. We do our best to help each person but some things are out of our control. If you are concerned about being on time, please phone us before your appointment to see how our timeline is moving. Please be kind to our reception team – they do their best.

This is your journey; we are here to help you along.

Thank you for choosing Chiropractors Geraldton – Straight Up Health!

Patient Name:

Address:

City/Town:

State:

Post Code:

Mobile:

Email:

Date of birth:

Gender

Male Female Other

Emergency Contact - Name:

Emergency Contact - Phone number:

Who may we thank for referring you?

What brings you in today?

If you are already experiencing a symptom, what is it?

How bad is it? How intense are your symptoms?

Please describe the areas of the body where you have pain or other symptoms:

How is this symptom / condition interfering with your personal life? (Select from each dropdown as appropriate)

Your work life?

Your exercise?

Recreation?

Your sleep?

Self-care?

Energy?

Attitude?

Patience?

Productivity?

Creativity?

From the dropdown, choose the option that best describes the direction that your health is currently headed.

What are your immediate health goals?

What are your short term health goals?

What are your long term health goals?

How many children do you have?

Children’s health concerns?

Children’s names and ages:

Are you currently pregnant?

No Yes

If you are pregnant, what is your due date?

Number of past pregnancies?

Health concerns during this pregnancy?

Please list any allergies:

Please list any medications you are currently taking:

Please list any supplements you are currently taking:

Please list any motor vehicle accidents you have had:

Please list any work-related incidents or injuries:

Please list any sports-related incidents or injuries:

Have you had any fractures or scars? If so, where and how did you get them?

Please list any operations you have had along with approximate dates:

Have you had chiropractic care before? If so, please complete the following questions:

Yes No

Name of Chiropractor:

Location:

When was your last adjustment?

When did the Chiropractor last take x-rays?

Is there anything else you would like to tell us about yourself or your life?

Chiropractors Geraldton

Straight Up Health

Opening Hours:

Monday: 8:30am – 6:00pm

Tuesday: 7:00am – 6:00pm

Wednesday: 8:30am – 6:00pm

Thursday: 8:00am – 6:00pm

Friday: 8:30am – 6:00pm

Saturday: 9:00am – noon

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Personal Health History Form

Chiropractors Geraldton Straight Up Health

Opening Hours:

Get in touch

Chiropractors Geraldton

Straight Up Health