新患者表格

My Details

Database
Preferred way of contact 首选联系方式
My Health

Have you ever had Chiropractic care before? 您以前接受过脊骨神经治疗吗?
How bad is it? How intense are your symptoms? 症状有多严重?
How committed are you to correcting this issue? 您有多大决心改善此症状/状况?
How is this symptom/condition impacting with your life? 此症状/状况对您的生活造成哪些影响?
In general, would you say your health is: 总体而言,您认为您的健康状况如何?
How would you rate your current level of stress? 您最近的压力水平如何?
How would you rate your sleep quality? 您的睡眠质量如何?
How often do you exercise for more than 30 minutes per day? 您每周进行超过30分钟锻炼的频率如何?
Do you suffer from repeated strains and/or sprains? 您是否经常拉伤或扭伤?
Do you have any repetitive movements daily? 您是否每天进行重复性动作?
In general, how would you rate your diet? 总体来说,您如何评价自己的饮食习惯?
Is this filtered water? 是过滤水吗?
Are you currently on any medication (including long term)? 您现在是否在服药(包括长期用药)?
Have you ever been hospitalised or had surgery? 您曾经住院或做过手术吗?
In the past few months have you experienced any of the following? 在过去几个月里,您是否有以下症状?
Have you ever suffered a heart attack or had a stroke? 您是否曾患过心脏病或中风?
Any children’s health concerns? 孩子有健康方面的担忧吗?
Are you currently pregnant? 您目前是否怀孕?
Health concerns regarding this pregnancy? 此次怀孕有健康问题吗?
AUTHORISATION FOR CARE 同意接受治疗声明

As with all health care professionals the law now requires practitioners who adjust the spine to inform patients of material risk. Chiropractic adjustments of the spine are internationally recognised as being safer in dealing with neck and low back pain than medication and many other alternatives. (A risk assessment of cervical manipulation, JMPT, 1995. Magna Report, Ontario Ministry of Health, 1993). In extremely rare circumstances some treatments of the neck may damage a blood vessel and give rise to a stroke or stroke like symptoms. This is extremely rare occurring in approx.. 1 in 5.85 million (Haldeman, et al. Spine, 1999, Vol 24-8). Whilst this has never occurred in this practice, we are still required to impart this information. Before you receive any adjustments, you will be tested to minimise risk, as has always been our practice. If you have any questions related to the care you are about to receive please speak to the chiropractor.

与所有医护专业人士一样,法律要求对接受脊椎调整的患者说明潜在风险。脊椎调整被国际公认为比药物和许多其 他方法更安全地治疗颈痛和腰痛(参考资料:《颈椎操作风险评估报告》,1995年;加拿大安大略卫生部《Magna 报告》,1993年)。在极为罕见的情况下,某些颈部治疗可能会损伤血管,引发中风或类似症状。这种情况极其罕 见,发生概率约为1/5,850,000(Haldeman等,《Spine》,1999年)。虽然本中心从未发生此类事件,我们仍有 义务告知您此风险。您在接受任何调整之前将接受检查,以最大限度地降低风险。这是我们一直以来的惯例。如您 对即将接受的治疗有任何疑问,请随时与脊骨神经医师沟通。

X-rays may be required in order to complete our examination and give us the most detailed information about the health of your spine. For safety purposes, female patients please answer the following questions: 我们可能需要进行X光检查,以帮助我们更详细地了解您脊柱的健康状况。为安全起见,请女性患者回答 以下问题:

Are you pregnant or trying to get pregnant? 您是否正在或计划怀孕?
Please indicate below if you give permission for the chiropractor to examine and administer care as deemed necessary. For patients under the age of 18, a parental guardian must indicate below. 如您同意让脊骨神经医师在必要时进行检查与治疗,请在下方签名。18岁以下患者需由监护人 签名。(Required)
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