CHIROPRACTIC

TOTAL WELLNESS CENTER DR. MELISSA ARCENEAUX-MYERS

Name

Referred by

MAJOR COMPLAINTS/SYMPTOMS

Pain Scale: (1-10)

Location of pain

Frequency of pain

Duration of pain

Has this condition previously occurred in the past

When first noticed

What/When triggers your symptoms (ex: morning, walking, exercising, sleeping etc)

What relieves your symptoms

Any radiating pain/shooting pain into extremity? Where?

What have you done for this condition on your own? Did it help?

Have seen other doctors for this condition?

Medication recommended and/or taking?

Surgery recommended/ History of previous surgeries

Previous Chiropractic Tx: (when/where?)

Previous X-ray/MRI/CT: (when/where?)

List and medical conditions/illnesses we should be aware of: (heart,liver,lung,ENT,GI,diabetes,cancer,dizziness,weight-loss, trauma,pacemaker/hardware)