Network Spinal New Patient Questionnaire Name * First Name Last Name DOB * Day/Month/Year Phone * Gender * Male Female Non-Binary/Gender Diverse Prefer not to say Address * Email * Emergency Contact * Name and Phone Number Occupation How did you hear about our office and Network Chiropractic? What do you hope to receive from our service in this centre? * What can we help you with? Past Chiropractic Care Have you ever had your spine or Nervous System examined professionally? Yes No If yes, by whom? Chiro/Physio/Specialist? Have you received chiropractic adjustments by a Doctor of Chiropractic? Yes No if yes; by whom, how often, and for how long, when was your last visit and if stopped, why? Please describe the reason for going, techniques or methods used Your specific needs and hopes from Simply Wellness Chiropractic Please tick your preference below to indicate how you want the network chiropractor to communicate with you about your spine, nervous system, health and wellness. Speak with me about the clinical findings and tell me about the changes I am making. Show me in written form the clinical findings and let me see the changes I am making. Let me get a sense of the clinical work, help me to feel the difference in my body. How important to you are the following aspects of your care in the first 2 months: Your opinion will help the practitioner tailor a management plan best suited to you It's important to see an improvement of my physical symptoms Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement of my emotional/mental symptoms Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement in my ability to react or respond to stress Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement in enjoyment of life and the ability to make constructive choices Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an overall improved quality of life Strongly Disagree Disagree Neutral Agree Strongly Agree How important to you are the following aspects of your care from 2 months and onwards It's important to see an improvement in my physical symptoms Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement of my emotional/mental symptoms Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement in my ability to react or respond to stress Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an improvement in enjoyment of life and the ability to make constructive choices Strongly Disagree Disagree Neutral Agree Strongly Agree It's important to see an overall improved quality of life Strongly Disagree Disagree Neutral Agree Strongly Agree Have you had or do you receive any of the following vehicles towards growth, healing and development? Bodywork Massage Osteopathy Craniosacral Therapy Meditation/Prayer Psychotherapy Movement or exercise Yoga/Dance/Tai Chi Acupuncture Re-Birthing Breath work Nutritional Support Somato Respiratory Integration (12 Stages of Healing) Ayurvedic/Oriental Medicine Part 2 - Stress Survey Where Was your birth? Home Birthing Centre Hospital Other What was the type of your birth? Natural (midwife/doctor) Instrument (forceps/suction) Breach (bottom first) Caesarean section (routine/emergency) How were you fed as an infant? Breastfed Bottle fed (breast milk) Bottle fed (formula) How long were you fed like this? Did your mother take medications while pregnant/breastfeeding? Yes No Was your birth induced by medications? Yes No Has your work exposed you to smoke, asbestos, coal dust, toxic fumes, etc.? Yes No Do you have a good quality of air in your home? i.e. void of smokers, away from main roads/pollutants Yes No Is the quality of your drinking water, tap or filtered, good? Yes No Is your diet low in preservatives/food additives or colouring? Yes No Have you had long term/short term use of alcohol? Yes No Have you had long term/short term use of tobacco? Yes No Have you had long term/short term use of illicit drugs? Yes No Have you had long term/short term use of coffee? Yes No Have you had long term/short term use of medications? Yes No Have you been vaccinated? Yes No If yes, do you know what for? Emotional Stress Was your childhood particularly stressful? Yes No Was your schooling stressful? Yes No Do you often partake in recreational activities, play or hobbies? Yes No Are you under stress from your family? Yes No Are you under stress from your personal relationships? Yes No Are you under stress concerning your health? Yes No Please make any further comments below concerning your emotional stress Physical Stress Please tick any appropriate traumas you have sustained Birth difficulties Childhood falls Sports injuries Motor vehicle accidents Repetitive strain injuries Employment related injuries Osteoarthritis Other Please make any further comments below concerning your past trauma How Do you grade your physical health? Excellent Good Fair Poor Worst Ever Medical trauma Have you been hospitalised? Yes No If yes, please detail in the space below i.e. when and what for Do you have, or have had any specific illnesses or diseases? Yes No If yes, please detail in the space below Have you ever had any broken bones? Yes No If yes, please detail in the space below where and when Have you had any surgeries? Yes No If yes, please detail in the space below when and what procedure Have you ever sustained any trauma that has knocked you unconscious? Yes No If yes, please detail in the space below when, how you were knocked out and for how long you were unconscious What are your hobbies/interests? Is there anything else, which may help us to understand you, which has not been discussed? Part 3 - Health Concerns or Symptoms How They May Affect Your Life Please list any additional health concerns that have not been addressed yet When did this situation begin? What have you done about this situation or concern What, if any, form of treatment or advice have you received for it Were the benefits sustained? Yes No What was different about YOU after treatment? What was different about YOUR CONDITION after treatment? What was different about HOW YOU FELT ABOUT THE CONCERN OR SYMPTOM after treatment? Grade the level to which your particular health concern affects these aspects of your quality of life My health concern affects my Work Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Eating Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Walking Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Sitting Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Recreations/Play Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Social life Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Relaxation Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Rest/Sleep Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Decision making Strongly Disagree Disagree Neutral Agree Strongly Agree My health concern affects my Exercise Strongly Disagree Disagree Neutral Agree Strongly Agree Have any other family members had the same or similar concerns? Yes No If yes, what did they do about them? Did this seem to work? What activity makes you more aware of your health concern? What activity makes you less aware of your health concern? Why do you think this has happened to you or continues to happen? If this condition went away tomorrow what would be different in your life? What are you doing in your life that is different to what you would be doing if you didn’t have this condition? Thank you! We will see you at your scheduled appointment time. Ellen and Lucie - Simply Wellness Chiropractic