Our records are entirely confidential.
  • SECONDARY SCHOOL AGE CHILD MEDICAL HEALTH FORM (13 years and above) Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form.
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  • Name*
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  • Date of Birth*dd/mm/yyy
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  • Please provide a brief description of your problem?*max 300 characters
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  • Do you know what caused your problem?*
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  • Has this occurred before and if so when?*
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  • Is the problem improving?*
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  • Are your symptoms worse during the day or at night?*
    Night
    Day
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  • At the onset of your problem, did you experience any trauma, illness/infection or other significant event?*
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  • Does your pain wake you at night?*
    Never
    Rarely
    Frequently
    Always
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  • Describe what aggravates/relieves your problem?*
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  • Have you had any other treatment for your current problem?*optional
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  • Who was the practitioner?*optional
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  • Did you find the treatment effective?*
    Yes
    No
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  • Please rate the severity of your symptoms*10 being the most severe pain (drag button)
    Pain Threshold0
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  • Does your current problem involve any of the following:*YesNo
    Pain in either arm and leg
    Tingling in either arm and leg
    Numbness in either arm and leg
    Weakness in either arm and leg
    "Weird" sensations in either arm and leg
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  • Please indicate yes/no to the following:*YesNo
    Do you think you have a healthy diet?
    Do you take vitamin supplements?
    Do you exercise regularly?
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  • Please list any sports/hobbies you have*
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  • Please comment on any signicant surgery and hospitalisation*
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  • Are you currently taking any form of medication? If Yes please list medications.*
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  • Do you have any other significant medical history?*Eg. Cancer, Diabetes, Heart Disease,/Hypertension, Asthma, Fractures, Sports Injuries, Falls
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  • Have you ever had a car accident? If Yes please describe?*No matter how trivial please describe details
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  • Please indicate yes/no to the following*YesNo
    Do you have frequent headaches?
    Do you feel stressed?
    Have you experienced dizziness/vertigo/faints/blackouts?
    Do you suffer from fatigue?
    Do you suffer from night sweats/fever?
    Do your joints swell?
    Have you lost/gained weight in the past year?
    Do you have digestive problems?
    Have you noticed any blood or mucus in your bowel movements?
    Do you suffer from shortness of breath or chest pain on exertion?
    Do you have any pain or increased frequency on passing urine?
    Do you have any unusual lumps/swelling on your body?
    Do you have any problems with hearing? (Including ringing in ears)
    Do you have any problems with smell or taste?
    Are you easily depressed?
    Do you suffer from anxiety?
    Do you have poor sleep?
    Do you have any problems with your vision?
    Do you have poor balance?
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  • I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.*
    I give consent
    I do not consent
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