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Medical History & General Health
MEDICAL HISTORY AND GENERAL HEALTH FORM
Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form.
Name
Date of Birthdd/mm/yyyy
Please provide a brief description of your problem?max 500 characters
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Has this occurred before and if so when?max 500 characters
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At the onset of your problem, did you experience any trauma, illness/infection or other significant event?max 500 characters
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Are your symptoms worse during the day or at night
Is the problem improving?max 500 characters
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Does your pain wake you at night?
Describe what aggravates/relieves your problem?max 500 characters
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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?
Please rate the severity of your symptoms10 being the most severe pain (drag button)
0
010
Could you be pregnant?Females only
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
Does your current problem involve any of the following:
YesNo
Do you currently smoke?
Do you currently drink alcohol?
Do you currently take recreational drugs?
Do you think you have a healthy diet?
Do you take vitamin supplements?
Do you exercise regularly?
Please list any sports/hobbies you havemax 300 characters
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Please comment on any signicant surgery and hospitalisationmax 500 characters
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Are you currently taking any form of medication? If Yes please list medications.max 500 characters
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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 (max 500 characters)
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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?
I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.
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