New Patient Forms

COST: Initial Consultations $150 - - - Ongoing Consultations $100

1. Cash on day of Consult

2. Pre-Pay to: Acct. Name: Mark S. Borsuk (ANZ)

BSB # 012754

Acct. # 586081177

MY PRACTICE RULES

Please no phone calls in the waiting area.

Please Park directly in front of my home or directly across the street.

Please be quiet & courteous to my neighbors.

If accompanied by children, please keep them seated quietly or in the

children’s area.

I require 24 hour notice for re-scheduling of your appointment, if missed;

you are responsible for payment.

I don’t respond to “UNKNOWN” or “PRIVATE” NUMBER on my phone. If you want to speak with me, make sure your number is visible to me.

_________________________________________________________________________

Name

Email Address*

Todays Date*

Mobile Number

Home Phone

Home Address

City

Children

Ages

Contact in emergencies

Phone

Who may we thank for referring you? How did you hear about us?

Occupation

Employer

Work Phone

What is the reason you are seeing me today?

How will you know when you are better?

When did your problem first appear?

What relieves it?

Is it getting worse, better, or staying the same?

What makes it worse?

Does it affect your daily living (work, sleep, exercise, etc.)? If so how?

What treatments have you had for this condition?

Are there any other symptoms you have?

Name of primary doctor or physician

Date of last physical

Dr's Address

Results

Have you ever seen a chiropractor or acupuncturist before?

Which?

List dates and types of surgeries you have had

Have you had any serious injuries? If so what and when?

Have you had any serious illnesses in the past?

Please list any hospitalizations both inpatient and outpatient treatments.

Please list any medications you currently take: prescription

Over the counter? How often?

Have you ever taken any antibiotics? For What? How Long?

Have you ever broken any bones?

Do you or have you ever played any sports? If so what?

In the process of getting well, what % of the responsibility do you think is your own/doctors?

Own

Doctors

Is there anything you are unwilling to change in order to get well?

What has prevented you from getting well in the past?

What do you feel is a reasonable time frame in which to reach satisfactory resolution of your complaint?

Please list the specific therapies, remedies and or treatments that you have tried that:

1. Have helped and continued to help.

2. Have been ineffective.

3. Helped at first but no longer does.

4. Has made you worse.

5. Have been suggested or prescribed that you do not follow.

Please list any additional information which would help us better understand your condition.

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