Borders Chiropractic New Patient Form

Please download and print this Word document or fill out the form and we will be in touch.

    Title (required) MrMrsMsMissDrOther

    First Name (required)

    Middle Initial

    Last Name (required)

    Address

    Home Phone

    Work Phone

    Mobile Phone

    Your Email (required)

    DOB

    Sex (required) MaleFemaleOther

    Occupation

    GP name and address:

    Do you have Health Inusrance? YesNo

    Is this a Personal Injury Claim? YesNo

    How did you hear about us?

    Medical history:

    Are you taking any medication (please list):

    Have you or any family member suffered with the following:
    (Hold down Ctrl button to select more than one at a time)

    Are you pregnant? YesNoN/A

    Please list any surgery you have had and when it was done:

    Please list any car accidents/significant injuries and when:

    Please list any serious illnesses you have had and when:

    By Using the list and image, please describe where you are experiencing the following symptoms in the text box below:

    • Numbness
    • Burning
    • Stabbing
    • Tingling
    • Dull Ache

    Describe your symptoms in order of severity, with worse symptom being #1:

    When did your symptoms begin?

    Are your symptoms a result of:
    Motor Vehicle AccidentWork related AccidentOther

    How did your symptoms begin?

    How often do you experience your symptoms?
    Constantly (76-100% of the day)Frequently (51-75% of the day)Occasionally (26-50% of the dayIntermittently (0-25% of the day)

    What describes the nature of your symptoms?
    SharpDull acheNumbShootingBurningTinglingStabbingOther

    How severe is your pain on a scale of 0-10?

    Have you had this problem before? YesNo

    What aggravates the problem?

    What relieves the problem?

    Any other associated symptoms?

    Any previous treatment?

    Is there anything else you feel it is important for us to know?

    Patient consent for telehealth:

    Telehealth consultations are done remotely, your practitioner will go over your medical information and specific information regarding your problem. We will carry out an examination by talking you through tests and specific movements, please ensure you are wearing suitable attire and have space to move around in. After this we will report what we have found and discuss your diagnosis, you will have the opportunity to ask any questions you have. Pain management advice, exercises and rehabilitation will then be discussed to treat your condition.

    Whilst we follow strict guidelines on best evidence based practice it is important to realise that any advice and treatment given cannot be guaranteed and is done at your own risk.

    By submitting this form you:

    • Give consent for my chiropractor to conduct a telehealth consultation and examination
    • Give my consent for the clinic to contact my GP or other healthcare professional in case of emergency or if clinically indicated
    • Give consent to be contacted by email/text/phone regarding appointments and treatment
    • Give consent to add my email to your mailing list- details will never be passed to any other party
    • Understand that my records will be stored securely by the clinic in accordance to GDPR.