Office Use Name(Required)
First
Last
Address(Required)
Male/Female(Required) Blood Type(Required) Relationship status(Required) Children Please add age and sex of each child
Since spinal cord tension results from the body's inability to adapt to any physical, chemical and emotional stress, it is extremely helpful for us to know as much as possible about your past and present stresses in all categories. Please answer these questions with as much detail as possible. Have you ever had your spine and/or nervous system examined professionally?(Required) Do you have any current health concerns, symptoms or blocks that interfere with the quality of your life? If yes please describe. Please include What, where, when, for how long etc
Please include What, where, when, for how long etc
Have you had experience with the following health, and/or healing modalities? If yes, please write WHEN and FOR WHAT did you go, HOW LONG and what were the RESULTS (successful "s" or unsuccessful "u")? Chiropractic(Required) When/for what/how long for/results (s/u)?(Required)
Massage/Bodywork/Bowen(Required) Massage or Bodywork or Bowen? When/for what/how long for/results (s/u)?(Required)
Emotional Therapy/Psychotherapy/Kinesiology(Required) Emotional Therapy or Psychotherapy or Kinesiology? When/for what/how long for/results(Required)
Osteopathy/Cranial work(Required) Osteopathy or Cranial work? When/for what/how long for/results(Required)
Physical Therapy/Occupational Therapy(Required) Physical Therapy or Occupational Therapy? When/for what/how long for/results(Required)
Music/Sound/Light/Aromatherapy(Required) Music or Sound or Light or Aromatherapy? When/for what/how long for/results(Required)
Homeopathy/Naturopathy(Required) Homeopathy or Naturopathy? When/for what/how long for/results(Required)
Ayurvedic Medicine(Required) When/for what/how long for/results(Required)
Oriental Medicine/Acupuncture(Required) Oriental Medicine or Acupuncture? When/for what/how long for/results(Required)
Nutritional Therapy/Colonic Hydrotherapy(Required) Nutritional Therapy or Colonic Hydrotherapy? When/for what/how long for/results(Required)
Oxygen Therapy/Chelation Therapy(Required) Oxygen or Chelation Therapy? When/for what/how long for/results(Required)
Reiki/Pranic/Theta Healing etc(Required) Reiki or Pranic or Theta Healing? When/for what/how long for/results(Required)
Rebirthing/Breathwork(Required) Rebirthing or Breathwork? When/for what/how long for/results(Required)
Yoga/Movement/Dance//Tai Chi/Chi Gong/Tri Breath(Required) Which of these/when/for what/how long for/results(Required)
Somato Respiratory Integration(Required) When/for what/how long for/results(Required)
NLP/The Landmark Forum/UPW/DWD/Holosync(Required) Which of these/when/for what/how long for/results(Required)
Family Constellations/Other(Required) When/for what/how long for/results(Required)
Do you exercise, meditate and/or pray?(Required) Please describe(Required)
Physical Stress When you get stressed, what do you do?(Required)
Birth Stress Was your mother outwardly ill prior to her pregnancy with you?(Required) Did your mother have a difficult pregnancy with you?(Required) Did your mother have any falls, accidents or any other physical injuries during the pregnancy?(Required) Was your birth traumatic?(Required) Was your birth: Describe any other physical or mechanical stress to your mother or you as the birthing process progressed, or as a newborn
General
Did you ever? (WHEN, HOW it occurred, WHAT body part was injured - L or R side) Fall from the cot or pram?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Fall down or up steps?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Fall on ice?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Have sport impacts?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Have physical fights?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Serve in the armed forces?(Required) When & how, any comments(Required)
Get knocked unconscious?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Use crutches, a walker or a cane?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Fracture any bones?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Severely sprain any joints?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Have any impacts, falls or jolts that you feel specifically have injured your spine?(Required) When & how did it occur, what body part was injured - L or R side(Required)
Have EXTENSIVE dental or orthodontic work performed?(Required) When & how did it occur, what body part was injured - L or R side(Required)
During the day I:(Required) I exercise:(Required) Are you active in any particular sports presently? Please describe
Were you active in any particular sports in the past? Please describe
Have you been hurt in any of these activities? Please describe what, when, how
Do you read for prolonged periods?(Required) Do you play a musical instrument?(Required) Do you have a particular position for watching television or scrolling on your phone?(Required) Do you wear:(Required)
Moving Vehicle Accidents: Have you ever (even as a passenger, even if you don't think you were hurt) been involved in an vehicular collison? Please list approximate dates, type of accident and severity (mild, moderate, extreme) Automobile: Please list approximate dates, type of accident and severity (mild, moderate, extreme)
Bus, motorcycle, train, aeroplane, moped or other vehicles: Please list approximate dates, type of accident and severity (mild, moderate, extreme)
Medical Treatment Have you ever been hospitalised?(Required) What was actually done to you and when?(Required)
Have you had surgery?(Required) What was done to you and when?(Required)
Do you still have all your body parts?(Required) What is missing?(Required)
Have you had:(Required) Please describe your menstrual cycle i.e. past/present, regularity, discomfort, use of pain killers and contraceptives etc.(Required)
Chemical Stress
Birth Stress Was your mother regularly taking any drugs immediately prior to, or during her pregnancy with you? i.e. alcohol, smoking, medication, other?(Required) Was her labour chemically induced or altered?(Required) During your delivery, was your mother:(Required) Any other chemical stress that your mother may have been subject to:
General Chemical Stress Are you CURRENTLY taking any drugs (prescription, over the counter or other)?(Required) Please list drugs, if prescribed, when prescribed and reason for taking them(Required)
Have you been vaccinated (including covid) or PREVIOUSLY taken any drug?(Required) Please describe(Required)
Do you or did you work with any chemical, fume, dust, powder or smoke for prolonged periods?(Required) Please describe(Required)
Please indicate how often you use/consume the following: Alcohol(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Coffee(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Tobacco(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Artificial sweeteners(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Refined sugars(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Filtered water(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Dairy products(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Cooked vegetables(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Raw vegetables(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Fruit(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Wholegrains(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Anti-perspirants(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Beef(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Lamb(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Fried foods(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Weight control diet(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Organic foods(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Poultry(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Fish(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Seafood(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Eggs(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Soy(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Fluoride treatments(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Fluoride toothpaste(Required) Do not use/consume this Use/consume this monthly Use/consume this a few times per month Use/consume this weekly Use/consume this a few times per week Use/consume this daily Use/consume this a few times per day
Emotional Stress
Birth Stress My birth was:(Required) After birth were you:(Required) Were you(Required)
General Emotional Stress
With the following emotional spinal stress situations, please select the option that applies (past/current, mild/moderate/extreme) or leave blank if n/a Childhood stress Past mild Past moderate Past extreme Current mild Current moderate Current extreme
School stress Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Play or recreational Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Family stress Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Personal relationships Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Stress of being sick Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Work related stress Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Stress of commuting Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Loss of loved one Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Change in lifestyle Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Change in vocation Past mild Past moderate Past extreme Current mild Current moderate Current extreme
Abuse Past mild Past moderate Past extreme Current mild Current moderate Current extreme
How do you grade your physical health?(Required) How do you grade your emotional health?(Required)
What do you hope to receive from care at this centre? Please rate the following: Improvement of my physical symptoms(Required) Very important to me Important to me Not so important to me Does not apply
Improvement of my mental/emotional symptoms(Required) Very important to me Important to me Not so important to me Does not apply
Improvement of my ability to react or repond to stress(Required) Very important to me Important to me Not so important to me Does not apply
Improvement in enjoyment of life and the ability to make constructive choices(Required) Very important to me Important to me Not so important to me Does not apply
Overall improved quality of life(Required) Very important to me Important to me Not so important to me Does not apply
What would you like to experience from attending our centre? Is there anything else that you would like to tell us?(Required)
