About Back Care chiropractic and medical imaging appointments

You can request an appointment with About Back Care on this website.

Before requesting an appointment through our online form, we ask for you to complete our patient questionnaire (below). The information you provide us will help us provide the best care for you, now and into the future. To complete the questionnaire, please fill out and submit the form below.

Alternatively, if you’d prefer not to complete the electronic form, you can download the form here, complete it and then either fax the form to us on (03) 9593 1876, or scan and email the form to info@brightonradiology.com.au. If you have trouble completing the form, contact us and we’ll be happy to go through it with you.

NOTE: PLEASE REFRESH THE PAGE BEFORE BEGINNING OUR PATIENT FORM BY CLICKING ON THE BUTTON BELOW.This will allow our special body discomfort-point tool to be correctly configured. On a mobile device, we advise completing the form in landscape mode.

After completing our patient questionnaire you will be forwarded to our online appointment request form.

    YOUR DETAILS

    (CONFIDENTIAL - YOUR PRIVATE INFORMATION IS USED ONLY BY US TO HELP YOU)

    Full name (required)

    Street address and number (required)

    Suburb (required)

    Postcode (required)

    Home phone

    Mobile phone

    Work phone

    Your email (required)

    Birth date (required - dd/mm/yyyy)

    Height in cms (required)

    Weight in kgs (required)

    Occupation

    How did you find out about our services?

    Had you ever had an MRI, CT scan or any other x-ray or imaging before?

    If you answered yes to the previous question, please provide details on when and why

    WHERE IS THE PROBLEM

    Please take a look at the diagrams below this form and click on the areas that are causing you discomfort or concern. If you make a mistake, simply click again to undo. You can select multiple areas if necessary.

    Right, Side
    1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556

    Back
    12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182

    Front
    12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879

    Left, Side
    123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051

    FINANCIAL

    I understand that this is a private chiropractic and imaging service and that this office does not hold accounts. In the event that there is an unpaid account, I will be liable for any administration costs charged to me. I agree that all services rendered to me are charged directly to me (No Medicare Rebate applies) and that I am personally responsible for payment.

    Your Name (required)

    Please indicate your acceptance of these financial terms by ensuring the box below is checked (required)

    Today's Date (required - dd/mm/yyyy)

    YOUR MAJOR COMPLAINT

    Please let us know the reason you require our services.

    Describe your main problem or symptoms

    When and how did is start (include approximate date started and duration)

    Was there any of the following prior to or during the onset
    Illness / infectionTraumaOther significant event

    Is your problem
    Getting worseNot changingImproving

    Is the pain
    Constantly thereIntermittent - on and off

    Describe what makes your symptoms worse

    Describe what relieves your symptoms

    Are your symptoms worse at night or any specific time of the day

    Do you get pain travelling down into your arms or legs

    if you answered yes to the previous question, please provide further details here

    Does your current pain involve any of the following?

    Tingling in either arm or leg

    if yes, describe where

    Numbness in either arm or leg

    if yes, describe where

    Weakness in either arm or leg

    if yes, describe where

    'Weird' sensations in either arm or leg

    if yes, describe where

    Have you ever had a stroke or heart attack?

    Have you seen anyone else for this current condition?

    if yes, please list their names

    Have you ever had this problem before?

    If yes, please describe, including how often

    Are you currently taking any medication, substances, vitamins, supplements, herbs?

    If yes, please list all items you are currently taking including the item's name and the reason you are taking it

    You have now completed your questionnaire. Please submit the details you have provided us by clicking on the button below.