If you are under 18, what is your mother's name?
If you are under 18, what is your father's name?
Date of Birth
If in a relationship, partner's name
Names and Ages of Children
Who referred you to Wave?
Have you ever received chiropractic care?
If yes, when was your last adjustment?
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.
Did your Mum and Dad...
Prepare their body for pregnancy?
Plan and welcome the pregnancy
Have chiropractic care during pregnancy?
Have a nutritious diet during pregnancy?
Exercise through pregnancy?
Smoke or drink alcohol during pregnancy?
Endure stress during pregnancy?
Growth and Development
Did you reach all your milestones?
Were you taught how to care for your spine?
Did you fall on your head?
Were you a head-banger/rocker?
Did you have any major accidents?
Did you have any surgery?
Physical abuse by siblings/other?
Did you play childhood sports?
If so, for how long?
If so, for how long
Was there any stress in the family?
Was there a loss of a family member/relative?
Was there communication breakdown in the household?
If yes to any of the above, please give details
Do you eat healthy foods?
Do you drink adequate water?
Do you drink any caffeinated drinks?
Are you physically stressed
Are you mentally stressed?
Are you taking or have you ever taken drugs/medication?
Do you exercise regularly?
Have you experienced a loss in the past 5 years (financial, relationship, family)
People consult Wave with one or more of the following health goals. Please indicate which apply to you.
You may have specific reasons for consulting Wave. If this is the case, what are they?
How would you rate your overall health, out of 10?
What would you like your health to be?