Patient Information Please fill in our online intake and history form thoroughly, answering each question to the best of your ability. *Please note that we will not be able to see if you haven’t completed this form. If there is any reason why you cannot fill this form in, please let us know asap and we can help you. Contact: info@lhcc.com.au or phone 07 3801 5288.Name (as appears on Medicare card) *Date *Mobile Phone: *Work Phone:Home Phone:Street *City/SuburbState/ProvinceSpouse DOB?AGE: *M/F/Other *Email: *Name/s of Children and DOB:Occupation:Employed by:Who Is Responsible For Account?Do You Have Private Health Insurance With Extras CoverYesNoWhat Company?Is Your Present Condition Covered By Workers Compensation?YesNoEmergency Contact: NameEmergency Contact Person NumberWho referred you to us?Referred ByFriend/RelationInternetFacebookOtherSignature:Choose FileNo file chosenDelete uploaded filePatient Case HistoryDear Patient: Please complete this questionnaire. Your answers will help us to determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.THIS IS A CONFIDENTIAL HEALTH REPORTCHECK OFF ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD OR HAVEGENERALAllergyDizzinessFatigueHeadacheLoss of sleepNervousness/depressionNumbnessGASTRO-INTESTINALBelching or gasColon troubleConstipationDiarrheaDifficult digestionGall bladder troubleHemorrhoidsLiver troubleNauseaPoor appetiteHiatus HerniaRESPIRATORYChest painChronic coughDifficult breathingAsthmaSKINBruise easilyDrynessItchingPsoriasisMUSCLE AND JOINTLow back painNeck pain or stiffnessPain between shouldersSwollen jointsArm painLeg painKnee painFoot painAnkle painHand painEYES, EARS, NOSE & THROATEarachesEnlarged glandsEye painSinus problemsBlurred visionHearing lossGENITO-URINARYBed wettingFrequent urinationPainful urinationKidney infectionProstate troubleTesticular painWOMEN ONLYExcessive menstrual flowIrregular cyclesPainful menstruationVaginal dischargeOvarian cystsFibroidsThrushCARDIO-VASCULARBlood pressurePoor circulationRapid heart beatSlow heart beatSwelling of anklesDescribe (front end/rear-end/T-bone? + any symptoms)Have you had chiropractic care before?YesNoName of Chiropractor and ClinicDate of last adjustmentDate of last X-rays takenNo X-rays takenNo XRsWhat is your major complaint?How long have you had this condition? When did it first start and why?What activities aggravate and what relieves your condition?What activities aggravate your condition?Is this condition getting progressively worse?YesNoConstantComes and goesIs this condition interfering with your: other – please listWorkSleepDaily routineOtherOther complaintsHow long has it been since you felt good?List surgical operations and years:Are you pregnant?YesNoDue Date:Exercise programs & sportsYour medical Doctor’s name and name of clinicDO YOU: Now take vitamins or minerals?Describe/List themNow take drugs of any kind?Describe/List themDATE OF LAST Spinal examinationLess than 6 months6-18 monthsOver 18 monthsNeverPhysical examinationLess than 6 months6-18 monthsOver 18 monthsNeverBlood testLess than 6 months6-18 monthsOver 18 monthsNeverChest x-rayLess than 6 months6-18 monthsOver 18 monthsNeverSpinal x-rayLess than 6 months6-18 monthsOver 18 monthsNeverDental x-rayLess than 6 months6-18 monthsOver 18 monthsNeverUrine testLess than 6 months6-18 monthsOver 18 monthsNever Please Bring Your Medicare Card To Your Consultation Medicare NameMedicare NumberMedicare CardChoose FileNo file chosenDelete uploaded file Send Message