New Patient Intake Form



I was told by family or friends
Referred by another health professional
Google or other search engine
Social Media
Health Engine
Clinic location
Meet us an a talk/event/expo


Yes
No

Poor
Average
Excellent

Yes
No
Unsure








Absolutely not!
Light
Moderate
Human chimney

No
Less than 5 per week
5-15 per week
Too many to count!

Yes
No

Excellent
Im working on it
Its not great but I don't care
My diet is so horrible, I don't know how I am alive





Numbness
Pins and Needles
Paralysis
Headaches
Migraines
Depression
Anxiety
Panic Attacks
Dizziness
Insomnia
Fainting
Previous Head Injury

Frequent Bloating
Frequent Nausea
Frequent Reflux
Stomach Cramps
Frequent Burping
Poor Appetite
Excessive Appetite
Vomiting
Diarrhoea
Constipation

Chest Pain
Chest tightness
Angina
Shortness of breath
Heart problems
Stroke
Asthma
DVT

Allergies
Sinus infections/problems
Dermatitis
Eczema
Earache
Frequent colds

Neck stiff/painful
Midback stiff/painful
Low back stiff/painful
Arm numbness/pain/pins and needles
Walking problems
Leg numbness/pain/pins and needles
Foot problems
Knee problems
Shoulder problems
Elbow or Hand problems

Overly painful periods
Irregular cycle
Problems conceiving or maintaining pregnancy
Hormonal Imbalance
Hysterectomy
Problems with Menopause


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I accept this policy.

I give my permission.
I am currently pregnant. I give my permission to take the x-ray image when the baby arrives.

I accept all 8 conditions found at https://belmontchiropractic.com.au/consent/
I have read and accept your T&Cs and Privacy Policy
Please sign within the box.





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