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1128 Kingston Road |
CHIROPRACTIC INTAKE HISTORY FORM
Headaches C
P
Neck Pain C
P
Stiff Neck C
P
Pins & Needles C
P
Arms/Legs C
P
Bowel Changes C
P
Bladder change C
P
Loss of Balance/Dizziness C
P
Persistent cough C
P
Sinus Problems C
P
Shortness of Breath C
P
Persistent skin sore C
P
Hypertension C
P
Joint pain C
P
Chest Pains C
P
Menstrual difficulties C
P
Fatigue C
P
Depression C
P
Chiropractic Care - Functional and Restorative
Pain relief only
Homeopathic Care - Constitutional care
Acute relief only
Nutritional Care - Overview of systems and needs assessment
detoxification protocols
Digestive Support - Overview of systems and needs assessment
Emotional Support - Neuro-Emotional Technique
Homeopathic care
Herbal care
Specialist referral
I would like remedies/nutritional adjuncts to speed my healing. 1
2
3
4
5
I want to address underlying causes of sickness and not just symptoms. 1
2
3
4
5
I am willing to perform recommended rehabilitative stretches and exercises. . 1
2
3
4
5
I might have had a health condition long before it now became symptomatic. 1
2
3
4
5
I am here to get out of pain. Nothing else, please. 1
2
3
4
5
Primary Insurance Company
Secondary Insurance Company
Thank you for your time and thoughtfulness in completing the above overview. You will have the opportunity to ask any questions you'd like and I will explain all diagnostic and therapeutic procedures thoroughly before they are performed and answer any questions you have concerning any possible risk to care.