Health Questionnaire

First Name

Last Name

Address

Home Number

Mobile Number

Date of Birth

E-mail

Occupation

Partner's Name

No. of Children

How did you hear about our clinic?

Do you have a current health/ life challenge or concern?

Have you ever injured your spine (neck, head, back, hips)?

Have you had any spinal X-rays, CT scans or MRI imaging?

Have you had any operations?

Please describe the overall level of chemical stress in your life, including drugs, smoking, alcohol and food

Has your spine ever been entrained/adjusted/manipulated?

What health treatments or healing modalities have you experienced? Please describe what the results were?

Are you aware of your posture? Please describe

Are you aware of your breath? Please describe

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