EMAIL 1 New Hatlen Family Chiropractic Patient Intake Form

HEALTH PROFILE
Healthy Posture = Relaxed Healthy Brain and Nervous System
Bad Posture = Stressed Unhealthy Brain and Nervous System
Make sure to click on the SUBMIT button on the last page.
Today's Date

MonthDayYear
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Height
Current weight
Ideal healthy weight
Gender*

FemaleMale
Address*

Street Address

Street Address 2

CityState

Zip Code
Phone Number*
E-Mail*
Social Security Number (For insurance)
Marital Status

SingleMarriedDivorcedWidowedSeparatedDomestic Partner
Spouse's/Partner's Name
Children
As part of my Pediatric Poor Posture Prevention Program, all of your children under 18 years old receive a complimentary computerized posture analysis. Would you like to have your children checked for abnormal posture?

YESNO
Occupation
Employer
Contact in case of Emergency
Emergency Contact Phone #
Whom may we thank for referring you to my office?
Name of your Health Insurance Company: (We will get a copy of your card in the office)

NoneAetnaAARP Medicare AdvantageBlueCross/BlueShield of ArizonaBlueCross/BlueShield City Of PhoenixBlueCross/BlueShield Out of StateCIGNAMedicare is my primaryOPTUM HealthUnited HealthcareAHCCCSOther
If you are here because you were recently involved in an auto accident or work-related injury, please select the date of injury below:
Date of Injury:

MonthDayYear
#1 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #1 health issue?
If your #1 health issue is not listed above then describe below:
Location: Which side(s) is your #1 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #1 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #1 health issue? (How many hours, days, weeks, months or years?)
Onset: Did your #1 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #1 health issue?
Timing: When is your #1 health issue the worst? (Check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #1 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingradiates to my left armradiates to my right armradiates to my left legradiates to my right legsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #1 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #1 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #1 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #1 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#2 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #2 health issue?
If your #2 health issue is not listed above then describe below:
Location: Where is your #2 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #2 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #2 health issue? (How many hours, days, weeks, months or years?)
Onset: What do you believe caused or is causing your #2 health issue?
Onset: Did your #2 health issue come on gradually or suddenly?

graduallysuddenly
Timing: When is your #2 health issue the worst? (Check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #2 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #2 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #2 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #2 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #2 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#3 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #3 health issue?
If your #3 health issue is not listed above then describe below:
Location: Where is your #3 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #3 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #3 health issue? (How many hours, days, weeks, months or years?)
Onset: Did your #3 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #3 health issue?
Timing: When is your #3 health issue the worst? (Check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #3 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #3 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #3 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #3 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #3 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#4 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #4 health issue?
If your #4 health issue is not listed above then describe below:
Location: Where is your #4 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #4 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #4 health issue? (How many hours, days, weeks, months or years?)
Onset: What do you believe caused or is causing your #4 health issue?
Did your #4 health issue come on gradually or suddenly?

graduallysuddenly
Timing: When is your #4 health issue the worst? (Check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #4 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #4 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #4 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #4 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #4 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#5 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #5 health issue?
If your #5 health issue is not listed above then describe below:
Location: Where is your #5 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #5 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #5 health issue? (How many hours, days, weeks, months or years?)
Did your #5 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #5 health issue?
Timing: When is your #5 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #5 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #5 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #5 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #5 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #5 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#6 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #6 health issue?
If your #6 health issue is not listed above then describe below:
Location: Where is your #6 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #6 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #6 health issue? (How many hours, days, weeks, months or years?)
Did your #6 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #6 health issue?
Timing: When is your #6 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #6 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #6 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #6 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #6 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #6 health issue negatively effecting your every day life?
#7 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #7 health issue?
If your #7 health issue is not listed above then describe below:
Location: Where is your #7 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #7 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #7 health issue? (How many hours, days, weeks, months or years?)
Did your #7 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #7 health issue?
Timing: When is your #7 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #7health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #7 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #7 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #7 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #7 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#8 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #8 health issue?
If your #8 health issue is not listed above then describe below:
Location: Where is your #8 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #8 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #8 health issue? (How many hours, days, weeks, months or years?)
Did your #8 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #8 health issue?
Timing: When is your #8 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #8 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #8 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #8 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #8 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #8 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#9 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #9 health issue?
If your #9 health issue is not listed above then describe below:
Location: Where is your #9 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #9 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #9 health issue? (How many hours, days, weeks, months or years?)
Did your #9 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #9 health issue?
Timing: When is your #9 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #9 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #9 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #9 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #9 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #9 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#10 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #10 health issue?
If your #10 health issue is not listed above then describe below:
Location: Where is your #10 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #10 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #10 health issue? (How many hours, days, weeks, months or years?)
Did your #10 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #10 health issue?
Timing: When is your #10 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #10 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #10 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #10 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #10 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #10 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#11 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #11 health issue?
If your #11 health issue is not listed above then describe below:
Location: Where is your #11 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #11 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #11 health issue? (How many hours, days, weeks, months or years?)
Did your #11 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #11 health issue?
Timing: When is your #11 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #11 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #11 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #11 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #11 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #11 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#12 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #12 health issue?
If your #12 health issue is not listed above then describe below:
Location: Where is your #12 health issue located?

LeftRightMiddleBoth sidesOther
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #12 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #12 health issue? (How many hours, days, weeks, months or years?)
Did your #12 health issue come on gradually or suddenly?

graduallysuddenly
Onset: What do you believe caused or is causing your #12 health issue?
Timing: When is your #12 health issue the worst? (check all that apply)

no differencemorningafternooneveningsleepingOther
Quality: Describe the sensation(s) of your #12 health issue. (Check all that apply)

achybugs crawlingburningcrampingdeepdullnaggingnumbnesspiercingsharpshootingstabbingstiffnessstingingthrobbingtinglingOther
Aggravates: What makes your #12 health issue worse? (Check all that apply)

nothingany movementbending head forwardbending head backwardtilting head to the lefttilting head to the rightturning head to the leftturning head to the rightbending forward at the waistbending backward at the waisttilting left at the waisttilting right at the waisttwisting left at the waisttwisting right at the waistchanging positionschewingdrivingexercisingliftinglaying on left sidelaying on right sidelying down on backreadingrunningsittingstandingstanding up from sittingwalkingworkingOther
Relieves: What makes your #12 health issue better? (Check all that apply)

nothingchiropractic adjustmentsanalgesic cream (ex. Biofreeze)anti-inflammatoriesexerciseheaticemuscle relaxersprescription pain medicationrestingstretchingTENS unitTylenolwalkingOther
Treatment: (Check all the treatments you have received for your #12 health issue prior to todays visit)

noneChiropracticanti-inflammatoriescortisone injectionsFunctional MedicineHomeopathic Medicinemassagemuscle relaxersNaturopathic MedicineNeurologistOrthopedic DoctorOsteopathic Doctor (DO)prescription pain medicationsphysical therapysurgerytrigger point injectionsOther
Life Effect: How is your #12 health issue negatively effecting your every day life?
On your desktop computer, hold down the left mouse button as you move the mouse to sign your name inside the box below. On your phone you can sign using your fingernail or stylus.
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HEALTH PROFILE

Healthy Posture = Relaxed Healthy Brain and Nervous System

Bad Posture = Stressed Unhealthy Brain and Nervous System

#1 HEALTH ISSUE

#2 HEALTH ISSUE

#3 HEALTH ISSUE

#4 HEALTH ISSUE

#5 HEALTH ISSUE

#6 HEALTH ISSUE

#7 HEALTH ISSUE

#8 HEALTH ISSUE

#9 HEALTH ISSUE

#10 HEALTH ISSUE

#11 HEALTH ISSUE

#12 HEALTH ISSUE

On your desktop computer, hold down the left mouse button as you move the mouse to sign your name inside the box below. On your phone you can sign using your fingernail or stylus.