Questions Form Contact us for Personal Support

Healthwise Assen: 0592- 398466
Healthwise Klazienaveen: 0591-239284
info@healthwisekliniek.nl

Healthwise Assen: 0592-398466
Healthwise Klazienaveen: 0591-239284

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Therapy
About us
Chiropractic
New Patient
Wellness Blog

Questions Form

As soon as we have processed your registration, we will contact you by telephone as soon as possible to make an appointment.

Please note: Questions with an ( * ) asterisk are mandatory.

Initials

First name

Last name

Maiden name

Date of birth

Address

Sex

Man Woman

Postal Code

residence

E-mail

Phone number

Mobile

Come through

Advertisement/article Family/acquaintance/friend Doctor Himself via internet Facebook Other

Are you married

Yes No

Number of children

Insurance

Insurance number

Profession

Are you currently working?

Yes No

Hobbies/Sports

BSN

General practitioner details

Initials

Last name

Salutation

Mr. Mrs.

Practice name

Practice email

Place

May we inform your GP?

Yes No

What is the main complaint

When did the complaint first start?

How did the complaint arise?

Gradual

variable present constant present

Suddenly

variable present constant present

Is there an appearance to

Arm on the right Arm on the left Leg on the right Leg on the left

Gets worse with

sitting walking standing bending down movement turning the head coughing/sneezing/straining other activities/poses:

Decreases by

sitting walking standing bending lying movement other activities/poses:

Experts
Have you been treated for these complaints by:

Chiropractor:

GP:

Physiotherapist:

Cesar/mensendieck:

Manual Therapist:

Podiatrist:

Neurologist:

Rehabilitation doctor:

Rheumatologist:

Acupuncturist:

Surgeon:

Pain team:

Homeopathic doctor:

Orthopedist:

Psychologist:

Alternative healer:

Otherwise:

Muscles and joints

Neck

Past problems Current problems

Between the shoulders

Past problems Current problems

Low back

Past problems Current problems

Tailbone

Past problems Current problems

Lies

Past problems Current problems left right

Hip

Past problems Current problems left right

Leg

Past problems Current problems left right

Knee

Past problems Current problems left right

Foot or heel

Past problems Current problems left right

Shoulder

Past problems Current problems left right

Arm

Past problems Current problems left right

Elbow

Past problems Current problems left right

Hand

Past problems Current problems left right

Wrist

Past problems Current problems left right

Fingers

Past problems Current problems left right

Rip

Past problems Current problems left right

Joint inflammation

Past problems Current problems

Swollen joints

Past problems Current problems

Arthritis

Past problems Current problems

Gout

Past problems Current problems

General

Headache

Past problems Current problems

Migraine

Past problems Current problems

Dizziness

Past problems Current problems

Pass out

Past problems Current problems

Tinnitus

Past problems Current problems left right

Insomnia

Past problems Current problems

Fatigue

Past problems Current problems

Nervousness

Past problems Current problems

Allergies

Past problems Current problems

Depression

Past problems Current problems

Facial pain

Past problems Current problems left right

Poor appetite

Past problems Current problems

Sinus inflammation

Past problems Current problems

Ear, nose, eye and/or throat complaint

Past problems Current problems

Sinusitis

Past problems Current problems

Deafness

Past problems Current problems

Ear infection

Past problems Current problems left right

Heart and vessels

Heart problems

Past problems Current problems

Stroke

Past problems Current problems

High bloodpressure

Past problems Current problems

Low bloodpressure

Past problems Current problems

Varicose veins

Past problems Current problems left right

Swelling in the ankles

Past problems Current problems left right

Poor circulation

Past problems Current problems

Anemia

Past problems Current problems

Stomach and intestines

Stomach ache

Past problems Current problems

Stomach ulcer

Past problems Current problems

Stomach rupture

Past problems Current problems

Bile problems

Past problems Current problems

Liver problems

Past problems Current problems

Constipation/difficult bowel movements

Past problems Current problems

Diarrhea

Past problems Current problems

Yield

Past problems Current problems

Hemorrhoids

Past problems Current problems

Flatulence

Past problems Current problems

Bladder, waterways problems

Past problems Current problems

Kidney inflammation

Past problems Current problems

Prostate problems

Past problems Current problems

Uncontrolled urine loss

Past problems Current problems

Appendicitis

Past problems Current problems

Skin

Itch

Past problems Current problems

Eczema

Past problems Current problems

Bruising

Past problems Current problems

Dry skin

Past problems Current problems

Women

Transitional problems

Past problems Current problems

Menstrual cramps

Past problems Current problems

Back pain during menstruation

Past problems Current problems

Irregular menstruation

Past problems Current problems

Excessive blood loss

Past problems Current problems

Have you had a miscarriage?

Past problems Current problems

Are you possibly pregnant?

Past problems Current problems

When was the last time you had your period:

Past problems Current problems

Miscellaneous

Conditions

Angina Pectoris Alcoholism Epilepsy Cancer Multiple sclerosis Polio Meningitis Rheumatism Tuberculosis Diabetes Mononucleosis Thyroid disorder Other

Dental

Do you grind or clench your teeth during the day and/or at night? you wear dentures, in whole or in part ? Do you ever feel tired in your jaws in the morning ? Do you have crowns ? Do you have a bridge ? Do you have a frame or plate in your mouth? Have you had braces in the past? Does the jaw joint sometimes make a popping sound?

Do you use

Arch raises left right Other

How do you sleep

Back Side Bulk Alternating How old is your mattress

Is your mattress comfortable

Yes No

Date of your last testing

Urine test

less than 6 months. between 6-18 months. longer than 18 months. never

X-rays

less than 6 months. between 6-18 months. longer than 18 months. never

Blood test

less than 6 months. between 6-18 months. longer than 18 months. never

Chiropractic. research

less than 6 months. between 6-18 months. longer than 18 months. never

Heart examination

less than 6 months. between 6-18 months. longer than 18 months. never

Habits

Appetite

Much Normal Little None

Coffee

Much Normal Little None

Alcohol

Much Normal Little None

Exercise

Much Normal Little None

Sleep

Much Normal Little None

Smoking

Much Normal Little None

Accidents

Broken bones

Operations

Hospital admissions

Mental illnesses

Medicines you take and for what purpose

Dietary supplements

Do you have any remarks?

Date

send to

Healthwise Assen Healthwise Klazienaveen

I understand that my medical information will be kept confidential and will only be shared with medical personnel if necessary for my treatment, and I voluntarily consent to chiropractic treatment at Healthwise Clinic.

I agree to the terms and conditions of the treatment and privacy statement

Your pain is our concern

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At Healthwise Kliniek we accurately and efficiently determine whether chiropractic treatments can help you with the health problems you are experiencing.

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0592-398466
info@healthwisekliniek.nl

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0591-239284
info@healthwisekliniek.nl

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