WAVE Chiropractic Maroochydore Chiropractor

WAVE Logo with background

07 5479 6910
6/6 Aerodrome Road, Maroochydore, QLD 4558

Opening
Hours

Initial Consultation Form

Wave Chiropractic

Welcome to Wave! We appreciate the opportunity to serve you. We ask you to assist us by completing the following questions.

Date
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Full Name
Please type your full name.

Preferred Name
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If you are under 18, what is your mother's name?
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If you are under 18, what is your father's name?
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Address
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Postcode
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Home phone
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Mobile
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Work phone
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Date of Birth
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Age
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Email
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Occupation
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Relationship Status
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If in a relationship, partner's name
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Names and Ages of Children
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Who referred you to Wave?
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Have you ever received chiropractic care?
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If yes, from whom?
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If yes, when was your last adjustment?
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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?
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Plan and welcome the pregnancy

Have chiropractic care during pregnancy?
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Have a nutritious diet during pregnancy?
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Exercise through pregnancy?
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Smoke or drink alcohol during pregnancy?
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Endure stress during pregnancy?
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Have any scans?
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Birth Process

Home birth?
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Hospital birth?
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Induced labour?
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Was your birth
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Drugs during delivery?
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Long delivery?
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Difficult delivery
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Caesarean (elective/emergency)?
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Growth and Development

Physical

Did you reach all your milestones?
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Were you taught how to care for your spine?
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Did you fall on your head?
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Were you a head-banger/rocker?
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Did you have any major accidents?
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Did you have any surgery?
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Physical abuse by siblings/other?
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Did you play childhood sports?
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Chemical

Take medication/drugs?
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Were you breast-fed?
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If so, for how long?
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Were you bottle fed?
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If so, for how long
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Vaccines received?
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Emotional

Was there any stress in the family?
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Was there a loss of a family member/relative?
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Was there communication breakdown in the household?
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If yes to any of the above, please give details
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Lifestyle

Do you eat healthy foods?
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Do you smoke?
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Do you drink alcohol?
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Do you drink adequate water?
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Do you drink any caffeinated drinks?
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Are your teeth healthy?
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Do you sleep well?
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Are you physically stressed
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Are you mentally stressed?
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Are you taking or have you ever taken drugs/medication?
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Do you exercise regularly?
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Sports/Hobbies
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Accidents
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Drugs/Medications
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Surgery
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Have you experienced a loss in the past 5 years (financial, relationship, family)
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Health Goals

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

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You may have specific reasons for consulting Wave. If this is the case, what are they?
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How would you rate your overall health, out of 10?
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What would you like your health to be?
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Validation(*)
Validation
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Contact Info

Opening Hours

Monday 2pm – 7pm

Tuesday 7am – 12pm, 3pm – 7pm

Thursday 7am – 11am, 3pm – 7pm

Saturday 8am – 11am

Phone

07 5479 6910 

Address

6/6 Aerodrome Road,
Maroochydore, QLD 4558

Email

info@wavechiropractic.com.au