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Body diagram
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Use this space to describe any other symptoms you are experiencing. Please indicate what is causing your symptoms
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Symptoms have persisted for number of
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Please select the following activities that AGGRAVATE your pain
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Others, please specify
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Please list any activities that RELIEVE your pain
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Others, please specify
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Please select any additional symptoms you may be experiencing
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What do you enjoy doing most when you are not working?
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Have you been treated by a physician for any health condition in the last year?
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Physician's Name
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Describe Condition
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Are you currently under the care of a physician, chiropractor, or physical therapist?
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If yes, please describe
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How many days per week are you exercising?
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Are you taking any supplements?
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Name of supplement
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Are you taking any medications?
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List
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Do you consume alcohol?
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If yes, how often per week?
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Do you smoke?
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Number of cigarettes per day
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Do you eat a balanced diet?
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Do you get adequate sleep?
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Do you have any allergies?
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List
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Are you pregnant?
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Months pregnant
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Have you ever been hospitalized
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If yes, for what and when?
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Have you ever had a surgical implant?
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Type
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Please list and date past surgeries
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MEDICAL/FAMILY HISTORY
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Sibling
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Mother
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Father
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Have you been in any Auto Accidents or had any Work-Related Injuries in the past year?
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If so, was it an
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Date of Accident/Injury
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Payment for Services will be by
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