hansson CHIROPRACTIC CENTRE
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1 hansson CHIROPRACTIC CENTRE 16 granby court, surrey close, weymouth dt4 9xb, , New Client Health Form Welcome to our Family Centre Our Chiropractic Mission is to Enable You to be the Best You Can Be Surname: Forename(s): Age: DOB: Address: Home Tel: Mobile: Work Tel: Occupation: Marital Status: S M D W Partners Name: No & Age of children: Previous Chiropractic Experience: when/where/why? Who may we thank for referring you? Name and Practice of GP What is your primary reason for attending the Centre? Your Goals:! Relief from Symptoms! Correction of Problems! Improved Health & Wellness I consent to a Chiropractic Analysis and. I understand that I will be required to wear a gown for this procedure (women). A chaperone is available and if I require one, I have informed a member of staff. I confirm that the information provided in this form is true and correct to the best of my knowledge. I confirm that I have received and read the satisfaction & complaints procedure document. Signed: Date:
2 YOUR BODY IS DESIGNED TO BE HEALTHY. If it is not, there is always a cause or reason. Throughout life many events occur that may damage your health. The following questions will help your Chiropractor assess any layers of damage, particularly to your nerve system, that have adversely affected your health. Please tick and complete where appropriate. All information will be handled in the strictest confidence. Your Birth The birth process can be quite traumatic for mother and baby and is often where spinal damage first occurs. Was your birth:! Unassisted! Forceps / Suction! Caesarean! Short duration! Premature! Induced! Breech! Drug assisted! Prolonged labour! Unsure Your Childhood Children often display symptoms of decreased health which may stem from spinal problems and/or nerve pressure. As a child did you suffer from:! Colic! Bedwetting! Ear Infections! Mumps! Allergies! Asthma! Eczema! Tonsillitis / Throat infection! ADHD! Behavioral problems! Dyslexia! Vaccination reaction! Measles! Sleep disruption! Chicken Pox! Other As a child were you: As a child did you:! Breast fed! A restless sleeper! A head banger! Have any major accidents! Have surgery! Require medication! Crawl before walking! Use a baby walker! Use a baby bouncer! Have a chair pulled! Fall down stairs! Sleep on your stomach from under you Comments: Were you vaccinated as a child: Women! Yes! No! Unsure Reproductive issues can place a strain on your body s resources. Chiropractic can help redress the nerve system balance. Have you or do you have:! Period Pain / discomfort! PMT! Irregular Periods! Chronic Thrush Have you experienced any fertility problems (please give details)? Number of full term pregnancies: Number of pregnancies not to term:
3 Have you experienced any problems during pregnancy (please give details): or during birth: Have you ever taken the Oral Contraceptive Pill?! Yes! No As the core problems get coated with layer upon layer of damage, symptoms and bouts of sickness may arise, demonstrating reduced levels of adaptability and health. Accidents Have you at any time suffered: General Health! Broken Bones Age & Details:! Motor Vehicle Accidents Age & Details:! Any Unconsciousness Age & Details:! Other Significant trauma Age & Details:! Bicycle Accidents Age & Details:! Horse Riding Accidents Age & Details: Have you ever suffered an illness requiring long-term hospitalization/medication?! Yes! No Details: Age: Do you take any medication or drugs (prescribed or otherwise)?! Yes! No Medication: Reason Duration Do you work with any! Chemicals! Dust! Smoke! Fumes! Powder Have you had any surgery as an adult or child?! Yes! No! Tonsils! Appendix! Adenoids! Hysterectomy! Other Have you ever had x-rays, scans or MRI (please give details and dates)? Do you or have you suffered with:! Headaches! Change/loss of vision! Diarrhoea! Prostate problems! Dizzyness! Hearing Change! Irritable Bowel! Urinary difficulty! Ringing in ears! Chest Pain! Cystitis! Pins & Needles! Hayfever! Shortness of Breath! Numbness! Urinary Tract Infection! Palpitations! Varicose Veins! Asthma! Arthritis/joint swelling! Heart Attacks/Angina! Fatigue / tiredness! Allergies! Eczema / skin disease! Stroke / TIA! Loss of balance! Indigestion! Rapid weight loss! High Blood Pressure! Incontinence! Ear Infections! Epilepsy/fits/seizures! Low Blood Pressure! Constipation! Cancer! Diabetes! Loss of consciousness! Jaw Clicking! Teeth removed! Orthodontic work! Other Comments:
4 Do you chew on one side?! Yes! No Comments Do you suffer with:! Work Stress! Physical Stress! Mental Stress During the day I! Sit! Stand! Walk! Do Desk Work! Drive! Do Mechanical Work! Heavy Lifting! Phone Work! Other Nutrition Do You: Smoke! Yes! No No. per day years Drink Alcohol! Yes! No Glasses per week Tea/Coffee! Yes! No cups per day Drink Water! 0 1 glass per day! 1 3 glasses per day! 4 8 glasses per day! more Eat fresh vegetables! 0 3 servings per week! at least 1 per day! several per day Eat fresh fruit! 0 3 servings per week! at least 1 per day! several per day Is there a family history of: Other Stresses! Heart disease! Arthritis! Cancer! Diabetes Which sports, hobbies or leisure activities do/did you engage in? Do you read/watch TV for prolonged periods i.e. more then 20 minutes?! Yes! No Do you play musical instrument?! Yes! No Which? Do you wear! Glasses! Bifocals/Varifocals! Contact Lenses What is your sleeping posture?! Side! Stomach! Back Have you ever been: Number of hours quality sleep per night: How many pillows do you use? How old is your mattress? Divorced?! Yes! No Date(s): Bereaved! Yes! No Details: Current Health What aspects of your health currently concern you?
5 Are you currently suffering any pain or illness? (Describe them & indicate the location on the diagram) L R R L How do these health concerns affect your family/friends/work? Please describe: Indicate on the following scale how you would rate your pain / discomfort on a scale of 1 10: 1 10 No Pain Extreme Pain On a scale of 1 10 how would you rate your health? Reasons: 1 10 Poor Excellent Is there anything else which may help to better understand you, which has not been discussed? Today is the first day of the rest of your life. Thank you for taking the time to complete this form.
6 HANSSON CHIROPRACTIC CENTRE Satisfaction & Complaints Procedure Dear Client Welcome to the office of Hansson Chiropractic Centre and an exciting future of health and wellness. Everyone in our team is committed to providing exemplary Chiropractic care in a fun, relaxed and educational environment and we look forward to sharing this with you. What we value above all else, is your satisfaction in our service. As such, whilst thankfully it is rarely required, we wish to take this opportunity to outline our procedure to address any concerns or complaints you may have in the future. We advise that you maintain a copy of this information with all other paperwork we provide. Our complaints procedure involves 4 stages. Should the first stage fail to resolve your complaint, you will be referred to the next stage. 1) Initially we will ask you to address your concerns in writing to the Chiropractor Mats Hansson/ Sarah Carter - who will attempt to address the issue to your complete satisfaction by speaking to you as soon as possible. If you would find it too difficult or uncomfortable speaking directly to Mats/Sarah the appropriate step is to refer to the next stage. However we hope that most clients will feel able to talk through concerns directly with Mats/Sarah after setting out the complaint in writing. 2) Should this be unsuccessful, or should you feel uncomfortable dealing with Mats/Sarah for any reason, we will refer you to our Team Leader Jasminka Hansson, or another Chiropractor should the issue require specific Chiropractic knowledge. 3) If a satisfactory outcome is not available via these avenues we will direct your concerns to our professional association The United Chiropractic Association. The UCA can be contacted by writing to the Peer and Ethics Committee at 1 st Floor, 45 North Hill, Plymouth, Devon PL4 8EZ or by telephone on With these 3 stages, if the complaint is upheld, consideration will be given to redress your concerns. The outcome of any of those 3 stages will be confirmed to you in writing. 4) Finally should the issue not have been resolved via any of these avenues, you can pursue a formal complaint to the General Chiropractic Council (GCC), the regulatory body of the Chiropractic Profession at 44 Wicklow Street, London WC1X 9HL. Should you consider contacting the GCC it is important to recognize that this represents a serious matter for the Chiropractor and a significant commitment from yourself. The GCC regulate Chiropractors and consider allegations of unacceptable professional conduct or incompetence. Thus this complaints process would be centered around the appropriate intervention for the Chiropractor if the case against him is found proved. Unlike our internal complaints stages and the UCA stage the GCC have no jurisdiction to award you compensation although they will meet your expenses for attending a hearing in London. The proceedings are formal like in a court of law. You will be asked to write a detailed letter of complaint (The GCC will be reluctant to pursue an anonymous complaint), they will ask you to see their solicitor and swear an affidavit, they will then ask you to attend at a hearing in London a number of months later and give formal evidence at a tribunal where you will be cross examined by a defense advocate and probably questioned by members of the tribunal. If the GCC find a case against the chiropractor proved the only options available to them are to admonish the Chiropractor, impose a conditions of practice order, a period of suspension or to strike the Chiropractor from the register. We hope that you feel you will never need to utilize these procedures and look forward to an exciting journey toward greater health and function. Yours in Chiropractic Mats Hansson/Sarah Carter Chiropractor
Adult New Client Medical History
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NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
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New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Pediatric Health Story Form
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BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
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Please complete the following as completely as possible. If you need assistance, please ask the front desk staff and they will be glad to assist you. Child s Name Date Parent(s) Name Siblings Names(Ages)
Initial Pain Management Patient Questionnaire
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PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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A new website is underconstruction with the latesest updated information. Please us ethe below as a general guide only.
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ACTIVE EDGE CHIROPRACTIC
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THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
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PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS.
Patient Entrance Form Michelle A. Gross, B.Sc. (Hons.), D.C. G. Murray Townsend, B.Sc., D.C. Brianne O Driscoll, B.Sc., D.C Name Date Date of Birth / / DAY MONTH YEAR Age Marital Status Home Address Town
Family Naturopathic Clinic
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Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S