To save time and allow us to better serve you, please complete all questions on the next pages. Thank you!
Addressing What Brought You Into This Office:
Throughout your life, have you ever had any accidents, falls, traumas, sport injuries or work injuries? Please note all accidents, even if they seem minor to you.
Throughout your life, have you had any surgeries or hospitalizations?
Pregnancy: (Female section)
Are there any diseases or illnesses in your family? If so, please specify.
Chiropractic is a global approach that takes into consideration all aspects of your health. The benefits of chiropractic are extended to all systems of the human body and an imbalance in your nervous system can manifest itself in many ways. It is therefore important for us to know your state of global health in order to offer you the best chiropractic experience.
Do you suffer from difficulties with your…(please check all that apply)
Stressors: Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had or are currently experiencing) in each category:
1. Physical stress (falls, accidents, work postures, etc.)
2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)
What are your expectations and goals by coming here, how might we be able to help you? Indicate your top 3 goals.
Why Chiropractic Care?
People go to a Chiropractor for a variety of reasons. Some go for symptomatic relief of a condition (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Still others want whatever is malfunctioning in their bodies brought to the highest state of health possible with chiropractic care (Preventative Care). These are the three phases of care. Your doctor will weigh your needs and desires when recommending your schedule of care. How long you choose to benefit from Chiropractic is always up to you.