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New NSA Referred Person Form

Referred NSA Person Information Form

This form is for people who have been referred to see me by their NSA practitioner.

1Personal Details

2Infant, Childhood and Adolescent Health

3Adult Health

4Stress Levels

5Current Health Concerns

6Health Concern 1

7Health Concern 2

8Health Concern 3

9Final Page

Date*
DD slash MM slash YYYY
Name*
First Last
Name you like to be called
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Date of Birth*
DD slash MM slash YYYY
Age
Email*
Required Information: Type “None” if you do not have an email address.
Mobile Phone*
Required Information: Type “None” if you do not have a mobile phone.
Home Phone
Work Phone
Gender*
- Female
- Male
Occupation
Name/s and Age of Children
Spouse/Partner/Supporter/Guardian's Name and Contact Number
Please enter the name of the NSA Practitioner who referred you.*
How long ago was your last NSA Entrainment visit?*
- Less than a week
- 1-3 weeks
- 3-6 weeks
- Over 6 weeks
How long have you been experincing NSA Care?*
- Less than a month
- 1-6 months
- 6 – 18 months
- Over 18 months
How often do you visit your NSA practitioer?*
- More than once a week
- Once a week
- Every 2 to 3 weeks
- Once a month
- Every 2 to 3 months
- Greater than 3 months
Rate your satisfaction with your previous NSA Care:
- Very Satisfied
- Satisfied
- Neutral
- Unsatisfied
- Very Unsatisfied
Any other comments about your NSA Care:

Infant, Childhood and Adolencent Health
As a baby child or adolescent did you experience significant physical stresses?
- Falls (e.g. out of cot, downstairs, off play equipment/bikes etc.)
- Physical abuse
- Fractures
- Sports injuries
- Other physical stresses
- No signifcant physical stresses
As a baby child or adolescent did you experience significant mental / emotional stresses?
- Family stress / relationship break up
- Mental/emotional abuse
- Bullying
- Relationship problems
- Changes in place of living
- Other mental/emotional stress
- No signifcant mental/emotional stresses
As a baby child or adolescent did you experience significant chemical stresses?
- Antibiotics before then age of 1 year
- Drug / alcohol abuse
- Environmental fumes or toxins
- Inadequate diet
- Other chemical stresses
- No signifcant chemical stresses

Adult Health
Tick the appropriate box for the conditions that apply to you. Leave blank if they do not apply.
Alcoholism
- Past condition
- Past and now
- Now
Allergy
- Past condition
- Past and now
- Now
Anaemia
- Past condition
- Past and now
- Now
Arthritis
- Past condition
- Past and now
- Now
Asthma
- Past condition
- Past and now
- Now
Back pain – low back
- Past condition
- Past and now
- Now
Back pain – mid back
- Past condition
- Past and now
- Now
Neck pain
- Past condition
- Past and now
- Now
Cancer
- Past condition
- Past and now
- Now
Constipation
- Past condition
- Past and now
- Now
Diarrhoea
- Past condition
- Past and now
- Now
Convulsions
- Past condition
- Past and now
- Now
Diabetes – Type 1
- Past condition
- Past and now
- Now
Diabetes – Type 2
- Past condition
- Past and now
- Now
Depression
- Past condition
- Past and now
- Now
Eczema
- Past condition
- Past and now
- Now
Emphysema
- Past condition
- Past and now
- Now
Epilepsy
- Past condition
- Past and now
- Now
Gall bladder condition
- Past condition
- Past and now
- Now
Gout
- Past condition
- Past and now
- Now
Headaches
- Past condition
- Past and now
- Now
Migraines
- Past condition
- Past and now
- Now
Hernia
- Past condition
- Past and now
- Now
Heart or Coronary artery disease
- Past condition
- Past and now
- Now
Heart arrhythmia / Palpatations
- Past condition
- Past and now
- Now
Heart attack
- Past condition
- Past with ongoing effects
- Recent
High Blood pressure
- Past condition
- Past and now
- Controlled by medication
- Now
HIV (AIDS)
- Past condition
- Past and now
- Now
Low blood sugar
- Past condition
- Past and now
- Now
Indigestion / Gastritis / Stomach ulcers
- Past condition
- Past and now
- Now
Malaria
- Past condition
- Past and now
- Now
Multiple Sclerosis
- Past condition
- Past and now
- Now
Anxiety
- Past condition
- Past and now
- Now
Nervousness
- Past condition
- Past and now
- Now
Neuritis
- Past condition
- Past and now
- Now
Mental Health condition
- Past condition
- Past and now
- Now
Pleurisy
- Past condition
- Past and now
- Now
Pneumonia
- Past condition
- Past and now
- Now
Rheumatic Fever
- Past condition
- Past and now
- Now
Tinnitus – ringing in ears
- Past condition
- Past and now
- Now
Sinus problems
- Past condition
- Past and now
- Now
Stroke
- Past condition
- Past with ongoing effects
- Recent
Thyriod – overactive
- Past condition
- Past and now
- Now
Thyriod – underactive
- Past condition
- Past and now
- Now
Sleep apnea
- Past condition
- Past and now
- Now
List any other adult conditions / diseases you have had or are experiencing now, which are not on the list above,
Recent or Current Symptoms
- Pain that wakes you at night
- Unexplained weight loss or gain
- Night sweats
- Numbness in arms, legs or body
- Loss of balance / dizziness
- Loss of energy / fatigue / weakness
- Breathing difficulties
- Loss of sense of smell or taste
- Memory loss
- Other unusual symptoms
List any medications (prescription or over the counter) that you are taking and the conditions you are taking them for.
List any supplements that you are taking and the conditions you are taking them for.
Have you ever been hospitalised?
- Yes
- No
Have you ever been operated on?
- Yes
- No
Do you have cramps or other pain associated with your menstrual cycle?
- Yes
- No
Is your your menstrual cycle regular?
- Yes
- No
Are you pregnant?
- Yes
- No
- Maybe
- Having difficulty with conception
Do you have menopausal symptoms?
- Yes
- No

Stress Levels
Stress, and the way it effects our lives, is the major factor which determines our state of health or illness. Unresolved stress not only causes us to express the symptoms of illness but reduces our ability to heal and grow. When we connect to the source of our stress, as happens with Network Care, it can be the fuel of healing and growth.
As an adult have experienced significant physical stressors?
- Falls
- Physical abuse
- Fractures
- Sports injuries
- Work injuries
- Motor vehicle accidents
- Working in constant posture (e.g. sitting/standing/bending for long periods
- Other physical stresses
- No significant physical stress
As an adult have experienced significant mental / emotional stressors?
- Death of a person close to you
- Mental / emotional abuse abuse
- Changes in place of living
- Loss of work / unemployment
- Relationship break up
- Financial pressure
- Other mental / emotional stresses
- No significant mental / emotional stress
As an adult have experienced significant chemical stressors?
- Smoking
- Medications
- Drugs / alcohol
- Unhealthy foods
- Fumes / environmental toxins
- Exposure to chemicals
- Other chemical stresses
- No significant chemical stress
Rate your stress level at work
- 1 No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Totally stressed
Rate your stress level at home.
- 1 No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Totally stressed
Rate your stress level at recreation.
- 1 No stress
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Totally stressed
Rate your Neck flexibility and movement.
- 1 Very stiff
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Very flexible
Rate your Mid Back flexibility and movement.
- 1 Very stiff
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Very flexible
Rate your Low Back flexibility and movement.
- 1 Very stiff
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Very flexible
Rate your Posture.
- 1 Poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 Excellent
Do you wear orthotics?
- Yes
- No

Current Health Concerns
The following questions relate to Health Concerns (symptoms or complaints) that you are currently experiencing. If the reason you are coming to see me is for Wellness Care and you don’t have any symptoms or complaints, please answer the first question and proceed to the final page of this questionnaire. Network Care aims to help you become more resourceful and make better choices in your life.
What is your primary motivation to book in to Enkindle Wellness now?
- To experience an increase in my level of Wellness
- A feeling that I can be healthier than I am now
- I have symptoms that I would like to explore
- I have significant health concerns
Health Concerns*
- I have health concerns
- I do not have health concerns

Health Concern 1
The following are a series of questions about your primary health concern
What is your primary health concern?
Name the complaint or symptom e.g. headache, asthma, period cramps, low back pain etc.
Rate the severity of the symptom /complaint.
- 1 mild
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 worst imaginable
When did this episode of your symptoms/condition start?
- Today
- Less than a week ago
- 1 to 2 weeks ago
- 2 weeks to a month ago
- 1 to 3 months ago
- 3 to 6 months ago
- Greater than 3 months ago
What do you think caused the symptom/condition?
If you have had this symptom/condition before, how long ago was that?
Did this problem begin with an injury
- Yes
- No
What percentage of the time is the symptom present?
- Less than 25%
- 25% to 50%
- 50% to 75%
- More than 75%, less than 100%
- 100%
Describe your pain.
- Sharp Pain
- Dull Pain
- Constant pain
- Intermitteny Pain
- Aching pain
- Radiating pain
- Shooting pain
- Burning pain
- No Pain
- Numbness
- Tingling
Since the symptoms/condition started has it:
- Much Better
- Somewhat Better
- About the Same
- Somewhat Worse
- Much Worse
Who have you seen about this Health Concern? Has it helped?
What activities / positions aggravate your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Twisting
- Walking
What activities / positions help your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Stretching
- Walking
Does your Health Concern 1 interfere with any of the following?
- Sleep
- Work
- Daily routine
- Sport / exercise
- Other
Type other activities that are interfered with here
Have you been "forced" or felt the need to make any positive changes as the result of this Health Concern?
E.g. eat better, change activity level, meditate etc.
What have you learnt about yourself from the healing process so far?
Have you had x-rays or scans done which are relevant to the present problem?
- Yes
- No
Do you have a second health concern?
- Yes
- No

Health Concern 2
What is Health Concern 2?
Rate the severity of the symptom /complaint.
- 1 mild
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 worst imaginable
When did this episode of your symptoms/condition start?
- Today
- Less than a week ago
- 1 to 2 weeks ago
- 2 weeks to a month ago
- 1 to 3 months ago
- 3 to 6 months ago
- Greater than 3 months ago
What do you think caused the symptom/condition?
If you have had this symptom/condition before, how long ago was that?
Did this problem begin with an injury
- Yes
- No
What percentage of the time is the symptom present?
- Less than 25%
- 25% to 50%
- 50% to 75%
- More than 75%, less than 100%
- 100%
Describe your pain.
- Sharp Pain
- Dull Pain
- Constant pain
- Intermitteny Pain
- Aching pain
- Radiating pain
- Shooting pain
- Burning pain
- No Pain
- Numbness
- Tingling
Since the symptoms/condition started has it:
- Much Better
- Somewhat Better
- About the Same
- Somewhat Worse
- Much Worse
Who have you seen about this Health Concern? Has it helped?
What activities / positions aggravate your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Twisting
- Walking
What activities / positions help your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Stretching
- Walking
Does your Health Concern 2 interfere with any of the following?
- Sleep
- Work
- Daily routine
- Sport / exercise
- Other
Type other activities that are interfered with here
Have you been "forced" or felt the need to make any positive changes as the result of this Health Concern?
E.g. eat better, change activity level, meditate etc.
What have you learnt about yourself from the healing process so far?
Have you had x-rays or scans done which are relevant to the present problem?
- Yes
- No
Do you have a third health concern?
- Yes
- No

Health Concern 3
What is Health Concern 3?
Rate the severity of the symptom /complaint.
- 1 mild
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 worst imaginable
When did this episode of your symptoms/condition start?
- Today
- Less than a week ago
- 1 to 2 weeks ago
- 2 weeks to a month ago
- 1 to 3 months ago
- 3 to 6 months ago
- Greater than 3 months ago
What do you think caused the symptom/condition?
If you have had this symptom/condition before, how long ago was that?
Did this problem begin with an injury
- Yes
- No
What percentage of the time is the symptom present?
- Less than 25%
- 25% to 50%
- 50% to 75%
- More than 75%, less than 100%
- 100%
Describe your pain.
- Sharp Pain
- Dull Pain
- Constant pain
- Intermitteny Pain
- Aching pain
- Radiating pain
- Shooting pain
- Burning pain
- No Pain
- Numbness
- Tingling
Since the symptoms/condition started has it:
- Much Better
- Somewhat Better
- About the Same
- Somewhat Worse
- Much Worse
Who have you seen about this Health Concern? Has it helped?
What activities / positions aggravate your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Twisting
- Walking
What activities / positions help your Health Concern?
- Sitting
- Lying in bed
- Getiing up from bed or chair
- Standing
- Bending
- Stretching
- Walking
Does your Health Concern 3 interfere with any of the following?
- Sleep
- Work
- Daily routine
- Sport / exercise
- Other
Type other activities that are interfered with here
Have you been "forced" or felt the need to make any positive changes as the result of this Health Concern?
E.g. eat better, change activity level, meditate etc.
What have you learnt about yourself from the healing process so far?
Have you had x-rays or scans done which are relevant to the present problem?
- Yes
- No
Do you have Health Concerns other than the ones above that you have filled out questions for?
List other Health Concerns here.

Final Page
Almost finished
Snapshot of you now.
The best starting point for any journey is to know where you are at the beginning.
My eating habits are:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My exercise levels are:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My sleeping pattern is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My mindset is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My energy level is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My physical health is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My emotional health is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My mental health is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My sense of Purpose is:
- 1 unsure
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 very clear
My overall health (physically, emotionally, mentally and spiritually) is:
- 1 Very poor
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 excellent
My health is:
- Getting better
- Not changing
- Getting worse
Is there anything else, which has not been mentioned, which would help me to understand you?
Thank you for taking the time to fill out this questionnaire. I look forward to meeting you and discussing with you, the answers that you have given me. Kind regards Ken Stewart

Δ

Enkindle Wellness

Dr Ken Stewart, Network Chiropractic

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