FV Male questionnaire - Mediterráneo Quiropráctica

Men English

We welcome you!

Our purpose is to help you live a life full of health, wellness and vitality. To get the most from life. This purpose may be very different from your previous experience. To find out how we can help you, we need to know what is wrong with you and what state is your body in.

This form takes a few minutes to fill in. Please answer ALL questions, they are important for us to determine how we can help you.

Gender

Other

Name

Lastname

Address, City and Zip code

ID Number

Date of birth and age

Phone number

Occupation

Marital Status

How did you meet us?

Mediterráneo Quiropráctica patient

Other (Internet, social networks...)

What would you say is your level of knowledge of chiropractic?

High

Medium

Low

Have you ever received chiropractic care?

Yes

What priority do you give to your health today?

What priority do you give to healing yourself today?

How can we help you?

What is your reason for coming here?

When did the symptoms start?

Days

Months

Years

What have you done so far to try to relieve this problem?

How does this problem affect your quality of life, how do you feel? Is there anything you can't do?

How will you feel when you get better?

How long have you been thinking about doing something for your health?

Days

Months

Years

What are your goals?

Just take the pain away

Remove the pain and prevent it from coming back

To be as good as possible (more health, happiness, vitality, better mobility...)

If you don't change anything, how do you see yourself in 10 years?

Getting worse

Getting better

How would you rate your health today?

Sick

Getting by

More or less healthy

Healthy and full of energy and vitality

Surgeries (date and surgery)

Hospitalisations (date and reason)

Accidents, falls, fractures, other (date and type)

Have you ever worn or do you wear insoles for shoes?

Yes

Do you always or almost always breathe through your mouth?

Yes

How many colds/flu have you had during the year?

1 - 2

3 - 4

Many

None

Quality of sleep. How do you feel when you wake up?

Tired

Rested

In what position do you sleep?

Face up

Face down

On your side

How is your blood pressure?

High

Low

Normal

Have you had or do you have braces? (If yes, please indicate for how long). Yes/No

How do you feel doing exercise?

I don´t do

I cant´t do

I don´t want to do

Exercising is difficult for me

Exercising is easy for me

Do you have any spinal studies to bring? X-ray, MRI, CT scan? If yes, please bring them with you on the day of your appointment.

Yes

Is there anything important in your medical history that you would like to tell us about?

Please indicate below if you have suffered/suffer from any of the following problems.

Do you take medication (indicate which and for what)?

Have you been diagnosed with any illness (indicate which one and treatment)?

What is your digestion like?

Frequency of toilet visits

How much water do you drink a day?

0L - 0,5L

0,5 L - 1L

1L - 1,5L

>1,5L

Do you smoke? If yes, please indicate how many per day

Have you ever smoked? If yes, please indicate for how long.

Do you drink coffee? How many cups a day?

Do you take supplements (vitamins, minerals, herbs...)?

Do you drink alcohol? If yes, please indicate the average intake per week.

What would you like to achieve with chiropractic care?

Have you had any emotionally difficult moments in your life (death of loved ones, break-ups, work problems...) Please indicate when they occurred.

Stress level at work

What hobbies or interests do you have?

COMMUNICATION PREFERENCES

Marketing communication

In compliance with the regulation (EU) 2016/679 on the protection of natural persons regarding the protection of personal data and the free circulation of this data and the Organic Law 3/2018 of 5 December on the Protection of privacy and guarantee of digital rights.

The data controller: MEDITERRANEO CHIROPRACTIC S.L. informs that the purpose of requesting the data is strictly necessary for the care.

The legitimacy of the data processing is for the administration of the requested service, regarding the contact data or identification data and regarding the health data according to the consideration 52 of the Regulation, which legitimizes the treatment of such data in the field of health.

Recipients: The data will not be shared with third parties except in cases where there is a legal obligation or where you expressly authorise us to do so.

Rights: You can access, rectify inaccurate data, oppose and delete your data, as well as other rights, by contacting the reception of the centre.

INFORMED CONSENT FOR CHIROPRACTIC CARE INFORMED CONSENT FOR CHIROPRACTIC CARE

Nature of chiropractic care:

The chiropractor uses his hands and / or a mechanical aid to adjust the spine. The existing techniques are varied and the chiropractor will use the ones that best suit your needs. Sometimes you can hear a "click" and you can feel the movement of the joint.

Possible complications of chiropractic care:

A minority of people experience an increase in symptoms or discomfort, such as muscle stiffness and tension, after the first adjustment sessions. Other very rare complications of chiropractic care are sprains, bone fissures, vascular injuries, and disc injuries.

Probability of complications after chiropractic care:

The probability of complications after chiropractic care is extremely low. There are poor quality studies that anecdotally link cervical adjustments with vascular lesions. However, epidemiological studies with the greatest statistical impact rule out this causal relationship. In fact, the risk of vascular injury after cervical adjustment is estimated to be one in a million to one in twenty million, depending on the source taken as reference. On the other hand, several scientific studies estimate that the risk of worsening a disc injury after receiving chiropractic care is approximately one in three million.

Declaration of express consent:

I declare that I have read and understood the content of this document and therefore I assume and accept the information that is described in its different sections. Based on this, I sign this document voluntarily, stating my express consent to receive chiropractic care by the undersigned.

I have read and agree to the Terms and Conditions and Privacy Policy.

I consent to this website recording my submitted information so that they can respond to my request.