Top Chiropractic

New Client Intake Questionnaire

41 Devonshire Street
London
W1G 7AJ
United Kingdom
02074952206

Our purpose at Top Chiropractic is to identify the underlying cause of your health concerns and to help you create a higher level of health so you can enjoy your life at its highest capacity. We achieve this from a natural and holistic perspective without the use of drugs or surgery.

We work from these core principles:

1. Your body is self healing, self regulating and self maintaining.

2. Your brain and nervous system form the master control system and communication network of your body that coordinates the function of every single cell to function together in harmony, as a whole.

3. Your spine and skull form the structure to support protect your brain and spinal cord.

4. Injury, imbalance, postural distortion or restricted movement of your spinal bones can cause interference to the nerve system and miscommunication between your brain and body. Many of the common health challenges that adults experience have their origins during the developmental years, some starting at birth.


We call this Vertebral Subluxation.



The role of a chiropractor is to identify and correct spinal imbalances that cause subluxation and nerve interference, thus allowing your child's brain and nerve system to heal, regulate and maintain all aspects of their body to their fullest capacity.



Please take your time to complete this form, the information you provide assists your Chiropractor in making the best care plan for your child as well as future recommendations. To help us in assisting your child in achieving your health goals for them, we need some important information about them.



Should you have any questions or are unsure about any of the questionnaire, please contact the the practice and we will be more than happy to help.

Please note: If cancelled less than 24 hours prior to the appointment, then the full fee will be charged.


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Personal Details

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First Name *

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Date of Birth

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