Medical History FormName*Date of Birth Date Format: MM slash DD slash YYYY Please provide a brief description of your problem?Has this occurred before and if so when?Are your symptoms worse during the day or at nightNightDayIs the problem improving?Does your pain wake you at night?NeverFrequentlyRarelyAlwaysDescribe what aggravates/relieves your problem?Have you had any other treatment for your current problem?Who was the practitioner?Did you find the treatment effective?YesNoPlease rate the severity of your symptoms-- 10 being the most severe pain --12345678910Could you be pregnant? (Female only)YesNo Does your current problem involve any of the following:Pain in either arm and legYesNoTingling in either arm and legYesNoNumbness in either arm and legYesNoWeakness in either arm and legYesNo"Weird" sensations in either arm and legYesNoDo you currently smoke?YesNoDo you currently drink alcohol?YesNoDo you currently take recreational drugs?YesNoDo you think you have a healthy diet?YesNoDo you take vitamin supplements?YesNoDo you exercise regularly?YesNoPlease list any sports/hobbies you havePlease comment on any signicant surgery and hospitalisationAre you currently taking any form of medication? If Yes please list medications.Do you have any other significant medical history?Have you ever had a car accident? If Yes please describe? Please indicate yes/no to the followingDo you have frequent headaches?YesNoDo you feel stressed?YesNoHave you experienced dizziness /vertigo /faints/blackouts?YesNoDo you suffer from fatigue?YesNoDo you suffer from night sweats/fever?YesNoDo your joints swell?YesNoHave you lost/gained weight in the past year?YesNoDo you have digestive problems?YesNoHave you noticed any blood or mucus in your bowel movements?YesNoDo you suffer from shortness of breath or chest pain on exertion?YesNoDo you have any pain or increased frequency on passing urine?YesNoDo you have any unusual lumps/swelling on your body?YesNoDo you have any problems with hearing? (Including ringing in ears)YesNoDo you have any problems with smell or taste?YesNoAre you easily depressed?YesNoDo you suffer from anxiety?YesNoDo you have poor sleep?YesNoDo you have poor sleep?YesNoDo you have any problems with your vision?YesNoDo you have poor balance?YesNoEmail* I consent for my information to be communicated to my GP and/or other relevant health professionals when appropriate.*I give consentI do not consentPhoneThis field is for validation purposes and should be left unchanged.
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