Patient

Primary Information
Had chiropractic treatment before?
Address
Professional
Marital Status
Health
Do you use :
Women Only
Financial Arrangements

Medical

Medical Symptoms Questionnaire
Head
Eyes
Ears
Nose
Mouth/Throat
SKIN
Heart
Lungs
Digestion
JOINTS / MUSCLES
Weight
Energy/Activity
Mind
Emotions
Other

Neck

Neck Disability Index Questionnaire
Section 1 - Pain Intensity
Section 2 - Personal Care
Section 3 - Lifting
Section 4 - Reading
Section 5 - Headache
Section 6 - Concentration
Section 7 - Work
Section 8 - Driving
Section 9 - Sleeping
Section 10 - Recreation
The Revised Oswestry Disability Index (for low back pain / dysfunction)
Section 1 - Pain Intensity
Section 2 - Personal Care
Section 3 - Lifting
Section 4 - Walking
Section 5 - Sitting
Section 6 - Standing
Section 7 - Sleeping
Section 8 - Social Life
Section 9 - Traveling
Section 10 - Changing Degree of Pain

History

Contact Information and Medical History
- Pain - Stiffness
- Numbness/tingling - Bruises, Open wounds

Agreement
Signature : ( in office )
Date:

Please cross check your information before submitting this order