0191 259 6777
Your body is designed to be healthy. There is always a cause or reason as to why it is not. Throughout life many events occur that may damage your health.
New Patient history:
Adults
Please fill in as much of this form as you can and tick where appropriate.
All the information you supply will be handled in the strictest of confidence. The answers will help us assess any layers of damage, particularly to your nervous system, that have adversely affected your health.
Areas marked with * must be filled in.

To use this form you must enter a valid email address.

Title Surname*
First names*
Preferred name
Address
Town
Postcode
Contact numbers
Day
Evening
Mobile
Email address*
Preferred contact method?
Date of birth
Age
Occupation
Marital status
Partners name
Names of children and their ages
Name of GP
Have you ever had chiropractic care?
Yes No
Why are you visiting
the clinic?
How did you hear about Naturally Chiropractic?
Your Birth
The birth process can be quite traumatic on both mother and baby and is often where spinal damage may first occur. Was your birth:
Unassisted
Forceps/Suction
Caesarean
Short duration
Premature
Induced
Breech
Drug assisted
Prolonged labour
Unsure
Your Childhood
Children often display symptoms of decreased health which may stem from spinal problems and/or nerve pressure. As a child did you suffer from:
Colic
Bedwetting
Ear Infections
Mumps
Allergies
Asthma
Eczema
Tonsillitis/throat infection
Measles
German Measles
Chicken Pox
Other
Add any other illnesses:
As a child were you:
Breast fed
A restless sleeper
A head banger
As a child did you:
Have surgery
A major accident
Crawl before walking
Fall down stairs
Use a baby bouncer
Use a baby walker
Require medication
Have a chair pulled from under you
Sleep on stomach
Use callipers
Have flat feet
Have turned feet
Were you vaccinated:
yes
no
unsure
Women Only
Reproductive issues can place a strain on your body’s resources. Chiropractic can help redress the balance. Have you had/do you have:
PMT
Period pain
Irregular periods
Chronic thrush
Have you experienced any fertility problems (please give details)?
Number of full term pregnancies
Number of pregnancies not to term
Have you had problems throughout pregnancy – please give details
Or problems with a birth – please give details
Have you been on the oral contraceptive pill
yes no
for how long
Accidents
Have you ever suffered from:
Motor vehicle
accidents
Fainting or
unconsciousness
Broken bones
Sprains
Other
Please give details including age
General health
Have you ever suffered from an illness which required hospitalisation or long term medication? Please give details and indicate your age.
Do you take any medication or drugs, either prescription/non prescription
Medication What for? How long?
Have you ever had surgery either as a child or an adult?
Tonsils
Appendix
Adenoid’s
Other
Please give dates, age and details
Have you ever had x-rays, scans or an MRI?
Please give dates, age and details
Have you had/do you have:
Headaches
Chest pains
Cold sweats
Palpitations
Loss of smell or taste
Dizziness
Loss of balance
Diabetes
Cystitis or bladder infections
Loss of
consciousness
Arthritis or
joint swelling
Swelling
of ankles
Eye problems
Loss of vision
Jaw pain or clicking
Hearing problems
Low blood pressure
High blood pressure
Asthma
Difficulty breathing
Eczema or
skin problems
Epilepsy, fits or
seizures
Diarrhoea
and constipation
Heart attacks
or angina
Strokes or T.I.A.’s
Varicose veins
Teeth grinding
Sinus problems
Pins and needles
Fatigue or tiredness
Orthodontic work
Allergic reactions
Numbness
Cancer
Teeth removed
Prostate problems
Indigestion
Rapid weight loss
Difficulty urinating
Other
Add any other symptons:
Do you suffer with:
Occupational Stress
Physical stress
Mental stress
Nutrition
Do you smoke?
yes no
number per day
Drink alcohol?
yes no
glasses per week
(not pints)
Do you drink water:
0-1 glass per day
1-3 glasses per day
4-8 glasses per day
More
Do you eat
fresh vegetables:
0-3 servings a week
at least 1 per day
several per day
Do you eat fresh fruit:
0-3 servings weekly
at least 1 per day
several per day
Family history
Did your Father suffer from:
Cancer
Heart disease
Arthritis
Diabetes
Other
Did your Mother suffer from:
Cancer
Heart disease
Arthritis
Diabetes
Other
Reason for visit
Are you suffering any pain or illness conditions at the moment?
yes no
Please describe the problem and indicate what part of your body
is being affected
How you would rate your pain/discomfort
on a scale of 1-10?
1 2 3 4 5 6 7 8 9 10

1 = No pain | 10 = Extreme pain

Which sports, hobbies or leisure activities do you engage in:
What is your sleeping position?
Side
Stomach
Back
How many hours of quality sleep do you
get per night?
How many pillows do you use?
How old is your mattress?
On a scale of 1-10 how would you rate
your health:
1 2 3 4 5 6 7 8 9 10

1 = Poor health | 10 = Excellent Health

Why do you say this?
Thank you for taking the time to fill in this form.
Declaration* The above information is to the best of my knowledge true and correct.
I have read and understood the ‘Informed Consent’ form and agree to proceed with care at Naturally Chiropractic.
Name Date
For under 18's: I give consent for to receive chiropractic care.
Parent/guardian name Date
*Access code: please type natchiro-adult in the box.
This so we know you are human.
Please note that by submitting this form you are giving us permission to contact you by the methods listed above. Your details will be held on our database but will not be passed to third parties at any other time.
Naturally Chiropractic: 1a St Oswins Place, Tynemouth NE30 4RQ0191 259 6777 info@naturallychiropractic.co.uk Sitemap HOME