North Brisbane and Ferny Chiropractic Clinic

Adult – New Patient Questionairre and Consent Form

(Strictly confidential)

Adult – New Patient Questionairre

Personal details

Title
Address
Address
Suburb
State
Postcode

Referral details

Who can we thank for referring you to us?

Accidents or injuries?

Health details

Which medication/s currently taken
Do you experience any of the following?
Is the problem?
Have you had a similar case before?
Does it interfere with?
Have you seen any other health professional about this problem?
Have you previously seen a chiropractor?
Was it for a similar condition?

Exercise/sports activities

North Brisbane and Ferny Chiropractic Clinic
Consent Form

Chiropractic care, when performed by a qualified Chiropractor has been found to be both effective and safe form of care for many health conditions. There are, however, risks associated with any treatment no matter how small, that you need to be informed of and we ask that you read the following carefully:

  • I understand there are very minimal risks resulting from treatment, such as but not limited to; muscle and joint soreness, sprain, muscle strain, disc injury, nerve irritation or damage.
  • I understand in extremely rare cases, some treatments to the neck may result in injury toblood vessels and give rise to stroke or stroke like symptoms.
  • I understand that results are not guaranteed and that consent can be withdrawn at any time.
  • I give consent for X-rays to be taken today if required.

Females only (for X-ray purposes)

Are you pregnant or likely to be pregnant?
  • I give consent, by signing below, to cover the entire course of treatment for my presenting complaint(s), and for any other future condition(s)for which I seek treatment from the below named Chiropractor and any of the registered Practitioners practicing at North Brisbane and Ferny Chiropractic Clinics.
  • I have read, or have had read to me the above consent and I have also had an opportunity to ask questions about this content.