Chiropractic – Initial Consultation Form

    We appreciate the opportunity to serve you and ask you to assist us by completing the following questions.

    Are you under 18 years old?
    YesNo

    How did you hear about us?

    Have you ever received chiropractic care?
    YesNo

    Your Health History

    About Your Life Journey

    The human body is designed to be healthy. Throughout the course of your life's journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they have likely had an accumulating effect on your life and health. Please answer the following questions regarding your life's journey.

    Pregnancy

    Did your Mum and Dad...
    Prepare their body for pregnancy?
    YesNoUnsure

    Plan and welcome the pregnancy

    Chiropractic care during pregnancy?

    Nutritious diet during pregnancy?

    Exercise through pregnancy?
    YesNoUnsure

    Smoke or drink alcohol during pregnancy?
    YesNoUnsure

    Endure stress during pregnancy?
    YesNoUnsure

    Have any scans?
    YesNoUnsure

    Your Birth

    Home birth?
    YesNoUnsure

    Hospital birth?
    YesNoUnsure

    Induced labour?
    YesNoUnsure

    Was your birth...
    EarlyLateOn due dateNot sure

    Drugs during delivery?
    YesNoUnsure

    Long delivery?
    YesNoUnsure

    Difficult delivery
    YesNoUnsure

    Caesarean (elective/emergency)?
    YesNoUnsure

    Growth and Development

    Physical

    Did you reach all your milestones?
    YesNoUnsure

    Were you taught how to care for your spine?
    YesNoUnsure

    Did you fall on your head?
    YesNoUnsure

    Were you a head-banger/rocker?
    YesNoUnsure

    Did you have any major accidents?
    YesNoUnsure

    Did you have any surgery?
    YesNoUnsure

    Physical abuse by siblings/other?
    YesNoUnsure

    Did you play childhood sports?
    YesNoUnsure

    Chemical

    Take medication/drugs?
    YesNoUnsure

    Were you breast-fed?
    YesNoUnsure

    For how long?

    Were you bottle fed?
    YesNoUnsure

    For how long?

    Vaccines received?
    YesNoUnsure

    Emotional

    Was there any stress in the family?
    YesNoUnsure

    Was there a loss of a family member/relative?
    YesNoUnsure

    Was there communication breakdown in the household?
    YesNoUnsure

    If yes to any of the above, please give details

    Lifestyle

    Do you eat healthy foods?
    YesNoUnsure

    Do you smoke?
    YesNoUnsure

    Do you drink alcohol?
    YesNoUnsure

    Do you drink adequate water?
    YesNoUnsure

    Do you drink any caffeinated drinks?
    YesNoUnsure

    Are your teeth healthy?
    YesNoUnsure

    Do you sleep well?
    YesNoUnsure

    Are you physically stressed?
    YesNoUnsure

    Are you mentally stressed?
    YesNoUnsure

    Are you taking or have you ever taken drugs/medication?
    YesNoUnsure

    Do you exercise regularly?
    YesNoUnsure

    Health Goals

    People consult Wave with one or more of the following health goals. Please indicate which apply to you.