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)
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