(02) 9299 0134
L4/65 York St, Sydney, 2000

Step 1

Male   Female
Day(s)
Week(s)
Months(s)
Years(s)
Better   Worse   Stays the same   Comes & goes  

Step 2

Date Describe the accident Eg: car accident Injuries Eg: whiplash Treatment Eg: hospitalized Add/Remove
 
No   Yes
Date Body part Add/Remove
 
No   Yes
Date Type of test and results if known Add/Remove
 
  • 01
  • 02
  • 03
  • 01
  • 02
  • 03
No   Yes (Please list here)
No   Yes (Please list here)

Step 3

Do you presently have, or have you had any of these conditions? Please circle
Anemia
Depression
Hypoglycemia (low blood sugar)
Thyroid conditions
Arthritis
Diabetes
Kidney Problems
Unexplained weight gain
Asthma
Frequent Headaches
Liver Problems
Chest pains
Heartburn
Osteoporosis/ osteopenia
Chronic colds Or Flu's
High Blood Pressure
Skin Conditions - rashes etc
No   Yes (If YES how often? )
No   Yes (If YES how often? )
PAIN AND FATIGUE SCALE
Next to each question assign a number between 0 and 5. You should assign values as follows
0 = NOT TRUE
3 = SOMEWHAT TRUE
5 = VERY TRUE

  • 01
    I experience problems falling asleep
  • 02
    I experience problems staying asleep
  • 03
    I frequently experience a second wind (high energy) late at night
  • 04
    I have energy highs & lows throughout the day
  • 05
    I feel tired all the time
  • 06
    I need caffeine (coffee, tea, cola, etc) to get going in the morning
  • 07
    I usually go to bed after 10pm
  • 08
    I frequently get fewer than 8 hours of sleep per night
  • 09
    I am easily fatigued
  • 10
    Things I used to enjoy seem like a chore lately
  • 11
    My sex drive is lower than it used to be
  • 12
    I suffer from depression, or have recently been experiencing feelings of depression such as sadness or loss of motivation
  • 13
    If I skip meals I feel low energy or foggy & disorientated
  • 14
    My ability to handle stress has decreased
  • 15
    I find that I am easily irritated or upset
  • 16
    I have had one or more stressful major life events (i.e.: divorce, death of a loved one, job loss, new baby, new job)
  • 17
    I tend to overwork with little time for play or relaxation for extended periods of time
  • 18
    I crave sweets
  • 19
    I frequently skip meals or eat sporadically
  • 20
    I am experiencing increased physical complaints such as muscle aches, headaches, or more frequent illnesses.
Unfit   Below average   Average   Above average   Very fit  

Step 4

VISUAL PAIN SCALE
Rate the pain:
(list each complaint on the line, then rate it from zero to ten)

  • 01
    None   2   3   4   5   6   7   8   9   10  
  • 02
    None   2   3   4   5   6   7   8   9   10  
  • 03
    None   2   3   4   5   6   7   8   9   10  
  • 04
    None   2   3   4   5   6   7   8   9   10  
  • 05
    None   2   3   4   5   6   7   8   9   10  
FEMALES ONLY

Yes   No   Maybe