Croydon Chiropractic Clinic

About Us

Services

Testimonials

Contact

Links

New Patient Registration

> Home > Appointments | New Patient Registration

Confidential Health History
This information is confidential. Your answers will help us determine if we can help you. If we do not sincerely believe your condition will respond, we will not accept your case. Please answer all questions truthfully even if you think they are irrelevant as only your chiropractor is qualified to determine whether there is a connection to your complaint.

Title:

Full Name:

DoB:

Address:

Town:

Postcode:

Home Tel:

Work Tel:

Mobile:

Occupation:

Email:

How did you hear about us:

Main area of complaint:

List any treatment you have received for this complaint:

List any medications you are taking:

Have you had Chiropractic care before:

Your GP's Details:

Name:

Address:

Permission for us to contact GP if required?:

Please tick any that have applied within the last 3 months:

headache	upper or mid back pain	anxiety
neck pain	nausea/vomiting	fatigue
neck stiffness	chest pain	depression
numbness in arms	shortness of breath	persistent coughing
double vision	lower back pain	bowel problems
dizziness	leg pain	bladder problems
shoulder/arm pain	numbness in legs or feet	sinus trouble
ringing in ears	blood pressure problems	change in weight
pain while walking	difficulty in standing	pain while standing
difficulty in walking	pain while sitting	difficulty in bending
pain while coughing	difficulty in rising to walk after sitting

Please tick the following conditions you have or have had:

Alcoholism	Anaemia	Arthritis	Diabetes
Eczema	Cancer	Gout	Heart disease
Infertility	Multiple Sclerosis	Osteoporosis	Stroke
Varicose Veins	Psoriasis	Aneurysm	Asthma
Thyroid problems	Any others…

Have you ever:

Been knocked unconscious	Had a fractured bone	Ever had surgery
Any personal injury or accident	Are you pregnant?	Do you smoke?

Have you ever been in an auto accident?	If yes, state when:

Consent to Examinations/X-Rays

I consent to an appropriate physical examination and X-ray’s if needed. Consent required by Parent/Guardian if patient is under 16 years of age. I understand that to the best of my knowledge the above to be an accurate health record. I understand that any X-rays or other diagnostic tests undertaken by this clinic remain the property of the clinic, and will only be released to other parties with prior agreement.

Fees Payable When Service Received Unless Special Arrangments Are Made.

"I've tried the rest and you're the best".

New Patient Registration