What is your main concern?
How long have you had this condition?
Have you had this or similar condition in the past?
Did your accident occur while at work? Yes/No
Is this condition getting progressively worse?
Yes/No Consistent/Comes & Goes
Is this a new or old injury? (circle one)
Was it treated before? Yes/No
If yes, what was done?
Name of Doctors.
Have you ever had surgery? Yes/No
Have you ever been hospitalized? Yes/No
Have you ever had Chiropractic care before? Yes/No
Name of Doctor.
Last time you had spinal x-rays or other x-rays?
Medications you now take.
From birth to present please list by date and describe.
-Falls/Injuries (including sports)