New Patient Form

Completing this before you arrive saves time in the clinic and helps us prepare for your visit. All fields marked * are required. We'll explain everything as we go and only proceed with care once you're completely comfortable.

Your privacy. The information you provide is confidential and collected only to assess and manage your care. It is stored securely and accessed solely by our clinical team. We will not share it without your consent, except where required by law. This online form is used to gather your details ahead of your visit; your clinical record is finalised in person. For full details see our Privacy Policy.

Personal Details

Full name *

Date of birth *

Street address *

Suburb *

Postcode *

Mobile *

Home phone

Email *

Occupation

Emergency contact name

Emergency contact phone

Do you have private health insurance?

Covered for chiropractic care?

Yes No Unsure

Is this condition related to WorkCover or TAC?

WorkCover TAC Neither

Your regular GP (General Practitioner)

Who may we thank for referring you?

Have you seen a chiropractor before?

Yes No

Major Complaint

What are you seeking help for today? *

When did it start?

How did it start?

Was any of the following present prior to or during onset?

Infection Trauma / Injury Illness Other significant event

Pain level right now (0 = none, 10 = worst imaginable)

Is it getting worse?

Yes No

What relieves it?

What aggravates it?

Are symptoms worse at night or a specific time of day?

Any pain travelling down your arms or legs?

Yes No

Does the problem involve any of the following? (tick all that apply)

Tingling in an arm or leg Numbness in an arm or leg Weakness in an arm or leg 'Weird' sensations in an arm or leg

Where is the problem? Describe the area(s) of discomfort.

Any other treatment for this problem so far?

Medical History & General Health

Vitamin / supplements (please list)

Previous surgery (please list, with year)

Current medications — please list ALL *

Do you take blood thinners / anticoagulants, or have osteoporosis?

Important for safe treatment — please flag either if relevant.

Blood thinners / anticoagulants Osteoporosis Neither

Are you pregnant, or could you be?

Yes No Unsure N/A

Serious health problems (e.g. hypertension, heart disease, diabetes, cancer)

Broken bones / fractures — which and how?

Falls or sports injuries — when and describe

Have you had any imaging taken recently of the areas you are seeking help for?

Such as MRI, CT scans or X-rays.

Yes No

Which Radiology centre have you had these taken at?

Family history of serious or hereditary disease (e.g. cancer, diabetes, heart disease)

Do You Suffer From Any of the Following?

Tick anything that currently applies to you.

Allergies (please list)

Prefer to fill it in by hand? Call us on (03) 9704 6567 and we'll have a paper form ready.