Patient Intake Form

NEKWERK Patient Intake Form

Please fill this out as carefully and as detailed as possible. Upon completion this form automatically generates and emails to me at info@nekwerk.nl . “Therefore it is not necessary to ask “please send via WhatsApp to +31640953724 or via email to info@nekwerk.nl. Jpeg or PDF is fine.” Thank you!

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- Step 1 of 9

A. Personal Information

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Full Name *

Date of Birth (DD/MM?YYYY)

BSN:

Address:

Postal Code:

City:

Phone Number:

Email Address: *

Emergency Contact Information:

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Name: *

Phone Number:

B. Referral

How did you hear about us?

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Friend (Name

Family (Name

Website (Google search? Other?

Other

C. Health Insurance

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Provider:

Policy Number:

D. Medical History

1. Current Medical Conditions (e.g., diabetes, hypertension, arthritis, neurological conditions):

2. Past Medical Conditions (Relevant past health issues, surgeries, hospitalizations):

3. Current Medications (Include prescription, over-the-counter, supplements):

4. Allergies (Include medications, foods, environmental factors):

5. Previous Injuries/Accidents (Especially relevant for musculoskeletal issues):

6. Family History (Conditions that may be hereditary, e.g., cardiovascular, arthritis, osteoporosis):

Michael Blackman Notes:

E. Chiropractic-Specific Information

1. Reason for Visit (Primary concern or reason for seeking chiropractic care):

2. Pain Description (Location, intensity, duration, type (sharp, dull, throbbing; chronic, new)

3. Injury Cause (Details about how the injury occurred, if applicable):

4. Previous Chiropractic Care (Prior treatments, frequency, and outcome):

5. Posture or Movement Concerns (Noticeable issues in posture, mobility, or stiffness):

6. Physical Activity Level (Daily exercise habits or lack thereof)

Michael Blackman Notes:

F. PEMF-Specific Information

1. Familiarity with PEMF Therapy (Have you undergone PEMF therapy before? For what purpose and what were the results?):

2. Health Conditions that affect use of PEMF (Pregnancy, malignancy, metal implants, or other devices):

G. Fall Prevention Testing Information

1. History of Falls or Near-Falls (How often and under what circumstances):

2. Balance Issues (Current problems with balance or unsteadiness):

3. Use of Assistive Devices (e.g., dogs, walkers, or other aids):

4. Footwear Preferences (Type of shoes worn regularly):

5. Physical Activity & Mobility Limitations (Difficulty with standing, walking, or stairs):

6. Medications that Affect Balance (Medications that could impair balance or increase fall risk):

Michael Blackman Notes:

H. Lifestyle Information

1. Occupation (Job-related physical demands, prolonged sitting/standing):

2. Sleep Patterns (Quality of sleep, hours per night, sleep posture):

3. Dietary Habits (Nutritional habits that could impact recovery):

4. Smoking and Alcohol Use (Frequency of use and habits):

I. Patient Goals & Aspirations

1. Treatment Goals (What do you hope to achieve, e.g., pain relief, improved mobility, etc)

2. Aspirations (e.g. running a marathon, losing 20kg, reversing osteoporosis, etc):

Michael Blackman Notes:

Thank you for completing this form, as it will go a long way to assist me in providing the custom care plan you deserve. I really look forward to discussing your responses in our session together. Please send via WhatsApp to +31640953724 or via email to info@nekwerk.nl.

NEKWERK Patient Intake Form

NEKWERK

Address:

Contact:

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