We appreciate the opportunity to serve you and ask you to assist us by completing the following questions. Name* Preferred Name* Are you under 18 years old? YesNo What are your parent's names? Address* Postcode* Phone Mobile* Work Phone Date of Birth* Age* Email* Occupation Relationship Status If in a relationship, partner's name Names and ages of children How did you hear about us? FacebookInstagramWebsiteGoogleLocationOther Who referred you to Wave? Have you ever received chiropractic care? YesNo Who was your previous Chiropractor? When was your last adjustment? Your Health History About Your Life Journey The human body is designed to be healthy. Throughout the course of your life's journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they have likely had an accumulating effect on your life and health. Please answer the following questions regarding your life's journey. Pregnancy Did your Mum and Dad... Prepare their body for pregnancy? YesNoUnsure Plan and welcome the pregnancy YesNoUnsure Chiropractic care during pregnancy? YesNoUnsure Nutritious diet during pregnancy? YesNoUnsure Exercise through pregnancy? YesNoUnsure Smoke or drink alcohol during pregnancy? YesNoUnsure Endure stress during pregnancy? YesNoUnsure Have any scans? YesNoUnsure Your Birth Home birth? YesNoUnsure Hospital birth? YesNoUnsure Induced labour? YesNoUnsure Was your birth... EarlyLateOn due dateNot sure Drugs during delivery? YesNoUnsure Long delivery? YesNoUnsure Difficult delivery YesNoUnsure Caesarean (elective/emergency)? YesNoUnsure Growth and Development Physical Did you reach all your milestones? YesNoUnsure Were you taught how to care for your spine? YesNoUnsure Did you fall on your head? YesNoUnsure Were you a head-banger/rocker? YesNoUnsure Did you have any major accidents? YesNoUnsure Did you have any surgery? YesNoUnsure Physical abuse by siblings/other? YesNoUnsure Did you play childhood sports? YesNoUnsure Chemical Take medication/drugs? YesNoUnsure Were you breast-fed? YesNoUnsure For how long? first 3 monthsfirst 6 monthsfirst 9 monthsup to about 1 yearmore than 1 year Were you bottle fed? YesNoUnsure For how long? first 3 monthsfirst 6 monthsfirst 9 monthsup to about 1 yearmore than 1 year Vaccines received? YesNoUnsure Emotional Was there any stress in the family? YesNoUnsure Was there a loss of a family member/relative? YesNoUnsure Was there communication breakdown in the household? YesNoUnsure If yes to any of the above, please give details Lifestyle Do you eat healthy foods? YesNoUnsure Do you smoke? YesNoUnsure Do you drink alcohol? YesNoUnsure Do you drink adequate water? YesNoUnsure Do you drink any caffeinated drinks? YesNoUnsure Are your teeth healthy? YesNoUnsure Do you sleep well? YesNoUnsure Are you physically stressed? YesNoUnsure Are you mentally stressed? YesNoUnsure Are you taking or have you ever taken drugs/medication? YesNoUnsure Do you exercise regularly? YesNoUnsure Sports/Hobbies? Accidents? Drugs/Medications? Surgery? Have you experienced a loss in the past 5 years (financial, relationship, family)? Health Goals People consult Wave with one or more of the following health goals. Please indicate which apply to you. Relief of my symptomCorrection of my underlying problemsTo maximise my healthTo maximise myself, my family's and my community's health You may have specific reasons for consulting Wave. If this is the case, what are they? How would you rate your overall health, out of 10? —Please choose an option—12345678910 What would you like your health to be, out of 10? —Please choose an option—12345678910
