Patient Questionnaire

Name

First Name Last Name

Date:

Month Day Year

Phone Number

Area Code Phone Number

Email

example@example.com

Please take several minutes to answer these questions so Dr. Graber can help you get better faster.

Check all that apply:

1. How have you taken care of your health in the past?

Medications Emergency Room Routine Medical Exercise Nutrition/Diet Holistic Care Vitamins Chiropractic

2. How did the previous method(s) work out for you?

Bad results Some results Great results Nothing changed Did not get worse Did not work very long Still trying Confused

3. How have others been affected by your health condition?

No one is affected Haven't noticed any problem They tell me to do something People avoid me

4. What are you afraid this might be (or beginning) to affect (or will affect)?

Job Kids Future ability Marriage Self esteem Sleep Time Finances Freedom

5. Are there health conditions you are afraid this might turn into?

Family health problems Heart disease Cancer Diabetes Arthritis Fibromyalgia Depression Chronic Fatigue Need surgery

How has your health condition affected your job, relationships, finances, family, or other activities? Please give examples:

What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples:

What are you most concerned with regarding your problem?

Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific:

What would be different/better without this problem? Please be specific:

What do you desire most to get from working with us?

What is that worth to you?

Patient Signature:

Date:

Month Day Year