Printable Patient Forms — for patients who prefer paper. Click a form below, then use your browser's Print function.
🤝
Phase 0 — New Patient
Initial Consultation
Health history, pain baseline, goals
⚡
Phase 1 — Active Care
Relief Care
Pain tracking, function, treatment feedback
💪
Phase 2 — Rehab
Rehab Phase
Functional ability, goals, exercise compliance
🌿
Phase 3 — Maintenance
Wellness & Maintenance
Spinal health, lifestyle, prevention
💡 How to use: Click Print on the form you need. Your browser will open the print dialog — select your printer or choose Save as PDF. Each form prints on 1–2 A4 pages with large, easy-to-read text and tick boxes.
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Banora Chiropractic
Patient Assessment Form
Initial ConsultationNew Patient — Phase 0
Patient Name —
Date —
D.O.B —
🩺
Chief Complaint
1 of 5
What is your main reason for visiting today?
How long have you had this problem? (circle one)
Less than 1 week
1–4 weeks
1–3 months
3–6 months
6–12 months
Over 1 year
Over 5 years
Lifelong
Where is your pain or discomfort? (tick all that apply)
Neck
Upper back
Mid back
Lower back
Shoulder / arm
Hip / leg
Head / jaw
Chest / ribs
Other:
📊
Pain Assessment
2 of 5
Circle the number that best describes your pain — 0 means no pain at all, 10 means the worst pain imaginable.
Pain right now
0
None
1
2
3
4
5
6
7
8
9
10
Worst
Average pain (past week)
0
1
2
3
4
5
6
7
8
9
10
Worst pain (past week)
0
1
2
3
4
5
6
7
8
9
10
What makes your pain worse? (tick all that apply)
Sitting
Standing
Walking
Bending
Lifting
Lying down
Morning
Evening
Exercise / activity
🏃
Function & Lifestyle
3 of 5
How much does your pain affect your daily life? (circle one)
No effect — fully functional
Mild — some limitations
Moderate — many limitations
Severe — very limited
How does it affect your work?
No effect on work
Reduces performance
Prevents some tasks
Unable to work
How is your sleep?
Good — no issues
Restless
Woken by pain
Very poor
Stress level (circle)
0
1
2
3
4
5
6
7
8
9
10
Occupation / type of work
📋
Health History
4 of 5
Have you seen a chiropractor before?
No, first time
Yes — good results
Yes — mixed results
Any relevant health conditions? (tick all that apply)
Arthritis
Osteoporosis
Diabetes
Heart condition
Cancer / history
Disc injury
Fibromyalgia
Anxiety / depression
Other:
Current medications (if comfortable sharing)
Any X-rays, scans or imaging relevant to this problem?
No imaging done
X-ray:
MRI:
CT scan
🎯
Goals & Expectations
5 of 5
What are your main goals from chiropractic care? (tick all that apply)
Reduce my pain
Improve movement & flexibility
Return to sport or exercise
Return to full work capacity
Improve my sleep
Improve energy & vitality
Long-term health maintenance
Better posture
What would a successful outcome look like for you?
How did you hear about us?
Friend or family
GP referral
Google search
Social media
Returning patient
Other:
Any additional notes or questions for your chiropractor?
For Clinic Use — Baseline Scores
Pain Score
Function Score
Sleep Score
Overall Score
🦴
Banora Chiropractic
Patient Assessment Form
Relief CareProgress Check-In — Phase 1
Patient Name —
Date —
Visit # —
🩻
Pain Levels
1 of 4
Pain right now (circle)
0
None
1
2
3
4
5
6
7
8
9
10
Worst
Worst pain this past week (circle)
0
1
2
3
4
5
6
7
8
9
10
How has your pain changed since your last visit? (circle one)
Much better
Somewhat better
About the same
Worse
🏃
Daily Function
2 of 4
How has your ability to do daily tasks changed? (circle one)
Much improved
Somewhat improved
About the same
More limited
How is your sleep this week? (circle one)
Good
Restless
Woken by pain
Very poor
Stress level this week (circle)
0
None
1
2
3
4
5
6
7
8
9
10
High
💬
Treatment Feedback
3 of 4
Have you been doing your home exercises? (circle one)
Yes — every day
Most days
Sometimes
Not yet
How did you feel after your last adjustment? (circle one)
Great — immediate relief
Better within 24 hours
Mild soreness then better
No noticeable change
Overall satisfaction with your care so far (circle one)
Very satisfied
Satisfied
Neutral
Unsatisfied
📝
Notes
4 of 4
Anything else you'd like your chiropractor to know?
For Clinic Use — Visit Scores
Pain Score
Function Score
Sleep Score
Overall Score
vs Baseline
🦴
Banora Chiropractic
Patient Assessment Form
Rehab PhaseAssessment — Phase 2
Patient Name —
Date —
Visit # —
🏋️
Functional Ability
1 of 4
Rate your ability for each activity — 1 = unable to do, 3 = can do with difficulty, 5 = fully able with no restriction
For each activity, circle your ability rating (1–5)
🏃 Walking 30+ minutes
1
Unable
2
3
Difficulty
4
5
Fully able
🏋️ Lifting / carrying
1
2
3
4
5
💺 Sitting 1+ hour
1
2
3
4
5
🔄 Bending forward
1
2
3
4
5
⚽ Sport / exercise
1
2
3
4
5
Pain at rest (circle)
0
None
1
2
3
4
5
6
7
8
9
10
Worst
Pain during activity (circle)
0
1
2
3
4
5
6
7
8
9
10
💪
Exercise & Rehab Program
2 of 4
How often are you doing your home exercises? (circle one)
Every day
4–5 times a week
2–3 times a week
Once a week
Rarely
Haven't started
How would you describe your exercise progression? (circle one)
Getting easier — progressing well
Staying the same
Still finding them difficult
Causing discomfort
🎯
Goal Achievement
3 of 4
Think back to the goals you set at your initial consultation. How far have you progressed towards each one?
Goal 1:
0% 100%
Goal 2:
0% 100%
Goal 3:
0% 100%
🌟
Feedback & Future Care
4 of 4
Are you interested in a maintenance care plan? (circle one)
Yes — weekly
Yes — fortnightly
Yes — every 3 weeks
Yes — monthly
Maybe — tell me more
No — not right now
Overall rating of your care (circle)
1
Poor
2
Fair
3
Good
4
Great
5
Excellent
Your biggest win or improvement since starting care
For Clinic Use
Pain Score
Function Score
Goal Score
Overall Score
vs Baseline
🦴
Banora Chiropractic
Patient Assessment Form
Wellness & MaintenanceHealth Check-In — Phase 3
Patient Name —
Date —
Visit # —
🩻
Spinal Health
1 of 4
Overall spinal comfort right now (0 = severe pain, 10 = completely pain free — circle)
0
Pain
1
2
3
4
5
6
7
8
9
10
Free
Any new areas of discomfort? (tick all that apply)
None — feeling well
Neck / upper back
Mid back
Lower back
Headaches
Hips / legs
Overall, compared to before you started chiropractic care (circle one)
Much better
Better
Slightly better
About the same
Worse
🌱
Lifestyle & Habits
2 of 4
Average daily sitting time (circle one)
Under 4 hours
4–6 hours
6–9 hours
9+ hours
Exercise or physical activity this week (circle one)
5+ days
3–4 days
1–2 days
None
Home exercises / stretching (circle one)
Yes — regularly
Sometimes
Rarely
Not doing any
🧘
Stress, Sleep & Wellbeing
3 of 4
Stress level this past week (circle)
0
None
1
2
3
4
5
6
7
8
9
10
Extreme
Sleep quality this week (circle one)
Excellent
Good
Fair
Poor
Energy levels this week (circle one)
Excellent
Good
Okay
Low / exhausted
🛡️
Prevention & Goals
4 of 4
What are you doing to support your spinal health? (tick all that apply)
Regular exercise / movement
Home exercises / stretching
Ergonomic workspace setup
Mindfulness / stress management
Good sleep habits
Anti-inflammatory diet
Any areas you'd like to focus on or questions for your chiropractor?