NEW PATIENT QUESTIONNAIRE
Date: ________
Last Name: ___________________
Gender:
Male
Female
Nationality :
First Name: ___________________
Middle: ______
Date of Birth: Day ______ Month_______ Year_________
Mobile No :
Home No:
Address/P.O Box :
Email address :
Marital Status :
Employed By:
Single
Married
Emergency Contact Name:
Divorced
Separated
Phone No:
MEDICAL HISTORY (please )
Past Medical History
Family History
YES
NO
Arthritis
Cancer
Diabetes
Epilepsy
General Fatigue/Tiredness
Heart Condition/Problem
High Blood Pressure
Kidney Problems
Liver Problems
Migraine
Thyroid Problems
Others
YES
NO
Arthritis
Cancer
Diabetes
Epilepsy
General Fatigue/Tiredness
Heart Condition/Problem
High Blood Pressure
Kidney Problems
Liver Problems
Migraine
Thyroid Problems
Others
If you have  YES to the above mentioned choices, please elaborate: ______________________________
_______________________________________________________________________________________
PAST SURGICAL HISTORY
YES
Allergies
Food
Medicine
Other allergies
Current Medication
NO
If yes, please indicate
CHIEF COMPLAINT
Which BODY PART you consider as your complaint? _______________________________
Please  your type of injury/case:
Sports Injury
Slip and Fall
Automobile
Other Trauma Incident
Wellness
How long has it been hurting? (PLS. BE SPECIFIC)________________________________
What activities make it worse? __________________________________________________
Have you had previous treatment for this condition?

Yes
No
If yes, check which provider and specify the DATE: _____________________
__Chiropractor
__Physiotherapist
__Osteopath
__Others_____________
If could explain below how and when it comes on :
Came on : __Gradually
It is getting __ Better Intensity: __ Minimal Frequency: __ Intermittent
__Immediately
__ Same
__ Slight
__ Occasional
__Worse
__ Moderate
__ Frequent
__ Severe
__Constant
Describe Feeling: __ Dull
__Sharp
__Aching __Shooting __Spasm
__ Numbing __Tingling
Other:
Location: __Right
__Left
__Antero-Lateral
Throbbing __Burning
__Postero-Lateral
ACTIONS EFFECTING THIS PAIN : (B)BRING ON (A)AGGRAVATE (R)RELIEVES
In the morning __B A__R In the afternoon __B A R Bending Forward __B A R
Bending back __B A R Bending left
__B A R Bending right
__B A R
Twisting right __B A R Twisting left
__B A R Coughing
__B A R
Sneezing
__B A R Straining
__B A R Standing
__B A R
Lifting
__B A R Sitting
__B A R Heat
__B A R
Cold
__B A R Rest
__B A R Lying Down
__B A R
Medication
__B A R
__ Nothing relieves the pain
Other 1 : ____________________
__B A R
Other 2 : ____________________
__B A R
Pain Radiates To :
Head: __ Right __ Left
Arm: __ Right __ Left
Leg: __ Right __ Left
Additional Comments :
Neck: __ Right __ Left Shoulder: __ Right __ Left
Hand: __ Right __ Left Hip:
__ Right __ Left
Foot: __ Right __ Left
LIFESTYLE
Describe your diet
Non - Vegetarian
Vegetarian
others_____________________
How many meals per day? _________________________
How many hours of sleep do you get a night?
less than 5 hours
more than 7 hours
5-7 hours
Is it interrupted?
Yes
No
How many glasses of water do you drink in a day?
less than 4 glasses
more than 7 glasses
5 - 6 glasses
What do you do to exercise? _______________________________________________
Are you under any stress?
Yes
No
Do you drink alcohol? If so how much? _____________________________________
Do you Smoke? If so how many? _______________
For females, are you pregnant?
Yes
No
Who referred you to our clinic? _____________________________________________
Who is your Insurance Provider? ____________________________________________
MEDICAL INFORMATION CONSENT
 I approve to release all medical and non-medical information in case of emergency for the purpose of treatment,
surgical procedure and settling payment, and as required by law.
CONSENT TO PROCEED WITH TREATMENT
 I, hereby authorise and grant permission to the treating doctor/therapist to proceed with the necessary treatment
and therapy required.

I, hereby confirm my full responsibility to settle my accounts.

I will ensure to cancel my appointment with at least 24hrs notices if I am unable to attend.
Further, I hereby attest that the information provided above by myself is accurate.
Patient/Guardian’s Signature: _________________________