Primary Complaint
Secondary Complaint
Additional Complaint
2. How does your current condition interfere with your:
10. Review of SystemsChiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please darken the circle beside any condition that you’veHad or currently Have and initial to the right.
Personal History.
11. Personal Illnesses
Check the illnesses you have Had in the past or Have now.
12. Operations
13. Treatments
Check the ones you’ve received in the Past or are receiving Currently.
14. Allergies
15. Injuries
16. Family History
18. Social History
19. Activities of Daily Living
Acknowledgements