New Patient Form

Name *

Email *

Phone

Date *

When and How did your symptoms start? *

When much of the day do you experience your symptoms? Mark where you feel your symptoms : *

0%-25%
26%-50%
51%-75%
76%-100%

Describe your symptoms: *

Are you symptoms... *

Getting Better
Not Changing
Getting Worse

Rate your symptoms. How do your symptoms affect your daily activity ? (1-10) *

What decreases your symptoms? *

What increases your symptoms? *

Who have you seen for your symptoms? *

Medical Doctor
Physical Therapist
Chiropractor
Other

Other Previous Treatment or Tests: *

X-Ray
CT Scan
MRI
Other

Have you experienced this before ? Yes / No What helped before *

What is your Job/Profession ? *

What are your Goals for Care ? *

Medications you are taking: *

Allergies: *

Surgeries/ Major Medical Procedures/Hospitalizations (with dates): *

What Number are You Now : *

Have you experienced any of the following in the Past or Present

Please describe any details for items marked above:

The definition of insanity is to keep doing the same thing and expecting different results. Clearly, it is time for a new approach or you wouldn't be here filling out this questionnaire. Have you made the decission to change and are you willing to do what it takes to be well?

Yes
No
Third Choice

What are some of your lifestyle choices that you feel may be contributing to your health problems?

What things that you have been unable to do as a result of your present symptoms

What things that you plan to do once you are feeling better

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