Dull Local Tension 􀂉 􀂉 􀂉 Aching Radiating 􀂉 􀂉 Since Your Symptoms Started, Are They: About the Same 􀂉 Getting Better 􀂉 Getting Worse 􀂉 What Have You Done to Help Your Condition? Ice 􀂉 Heat 􀂉 Pain Relievers 􀂉 Massage 􀂉 Stretching 􀂉 What Activities Aggravate Your Condition? Sitting Concentrating Running 􀂉 􀂉 􀂉 Standing Dancing Shoveling 􀂉 􀂉 􀂉 Working Chores Sleeping 􀂉 􀂉 􀂉 Bending Dressing Walking 􀂉 􀂉 􀂉 Carrying Driving Lifting 􀂉 􀂉 􀂉 Climbing Pushing 􀂉 􀂉 Have You Seen Anyone Else for This Condition? (Chiropractor, Family Practitioner, MD, Etc.) Yes 􀂉 No 􀂉 General Health History Chiropractic is concerned with how your nervous system Have you ever had any of the following diseases or conditions? is functioning. If it is not functioning at 100%, a multitude of problems can occur. CERVICAL SPINE (Neck): Do you experience…? Neck Pain Headaches Sinusitis/Allergies 􀂉 􀂉 􀂉 Pain into Shoulders/Arms/Hands Dizziness 􀂉 􀂉 Numbness/Tingling in Arms/Hands Visual Disturbances 􀂉 􀂉 Coldness in Hands TMJ/Pain/Clicking 􀂉 􀂉 THORACIC SPINE (Upper back): Do you experience…? Heart Palpitations/Murmurs Recurrent Lung infections/Bronchitis Asthma/wheezing 􀂉 􀂉 􀂉 Heart Attacks/Angina Pain into Ribs/Chest Mid-Back Pain 􀂉 􀂉 􀂉 Pain on Deep Inspiration/Expiration Ulcers/Gastritis 􀂉 􀂉 Indigestion/Heartburn/Reflux 􀂉 LUMBAR SPINE (Lower back): Do you experience…? Pain into Hips/Legs/Feet Recurrent Bladder Infections Low Back Pain 􀂉 􀂉 􀂉 Numbness/Tingling in Legs/Feet Frequent/Difficulty Urinating Constipation/Diarrhea 􀂉 􀂉 􀂉 Coldness in Legs/Feet Muscle Cramps in Legs/Feet Menstrual Irregularities/Cramping 􀂉 􀂉 􀂉 Accumulations of Stress The following areas of stress can contribute to your loss of to heal and repair. health and influence our body’s ability PHYSICAL STRESS Slips/Falls 􀂉 Sleeping Position 􀂉 Repetitive Heavy Lifting 􀂉 Continuous Sitting/Standing 􀂉
􀂉 Dull 􀂉 Local 􀂉 Tension 􀂉 Aching 􀂉 Radiating Since Your Symptoms Started, Are They: 􀂉 About the Same 􀂉 Getting Better 􀂉 Getting Worse What Have You Done to Help Your Condition? 􀂉 Ice 􀂉 Heat 􀂉 Pain Relievers 􀂉 Massage 􀂉 Stretching What Activities Aggravate Your Condition? 􀂉 Sitting 􀂉 Concentrating 􀂉 Running 􀂉 Standing 􀂉 Dancing 􀂉 Shoveling 􀂉 Working 􀂉 Chores 􀂉 Sleeping 􀂉 Bending 􀂉 Dressing 􀂉 Walking 􀂉 Carrying 􀂉 Driving 􀂉 Lifting 􀂉 Climbing 􀂉 Pushing Have You Seen Anyone Else for This Condition? (Chiropractor, Family Practitioner, MD, Etc.) 􀂉 Yes 􀂉 No General Health History Have you ever had any of the following diseases or conditions? Chiropractic is concerned with how your nervous system is functioning. If it is not functioning at 100%, a multitude of problems can occur. CERVICAL SPINE (Neck): Do you experience…? 􀂉 Neck Pain 􀂉 Headaches 􀂉 Sinusitis/Allergies 􀂉 Pain into Shoulders/Arms/Hands 􀂉 Dizziness 􀂉 Numbness/Tingling in Arms/Hands 􀂉 Visual Disturbances 􀂉 Coldness in Hands 􀂉 TMJ/Pain/Clicking THORACIC SPINE (Upper back): Do you experience…? 􀂉 Heart Palpitations/Murmurs 􀂉 Recurrent Lung infections/Bronchitis 􀂉 Asthma/wheezing 􀂉 Heart Attacks/Angina 􀂉 Pain into Ribs/Chest 􀂉 Mid-Back Pain 􀂉 Pain on Deep Inspiration/Expiration 􀂉 Ulcers/Gastritis 􀂉 Indigestion/Heartburn/Reflux LUMBAR SPINE (Lower back): Do you experience…? 􀂉 Pain into Hips/Legs/Feet 􀂉 Recurrent Bladder Infections 􀂉 Low Back Pain 􀂉 Numbness/Tingling in Legs/Feet 􀂉 Frequent/Difficulty Urinating 􀂉 Constipation/Diarrhea 􀂉 Coldness in Legs/Feet 􀂉 Muscle Cramps in Legs/Feet 􀂉 Menstrual Irregularities/Cramping Accumulations of Stress The following areas of stress can contribute to your loss of health and influence our body’s ability to heal and repair. PHYSICAL STRESS 􀂉 Slips/Falls 􀂉 Sleeping Position 􀂉 Repetitive Heavy Lifting 􀂉 Continuous Sitting/Standing