Adult Form - Chiropractic On Eagle Page 2

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Please check all that apply:
Low Back Pain
Numbing-Tingling in
Asthma/allergies
Pain Between Shoulders
Hands/Feet
Menstrual Cramps
Neck Pain
Numbing-Tingling in
Weight Trouble
Headaches / Migraines
Arms/Legs
Foot /Ankle Pain
Tired / Fatigued
Dizziness
Mood swings
Tight Muscles
Ringing in Ears
Upset stomach
Fibromyalgia
Nervousness
Sexual dysfunction
Tension across shoulders
Attention Deficit Disorder
Ankle swelling
Stress
Frequent colds
Bladder trouble
Forgetfulness
Difficulty Sleeping
Heartburn
Miscarriage(s)
Thyroid problems
Chest pain
Liver/gall bladder
depression
Walking problems
problems
Allergies / Sinus Problems
Confusion
High blood pressure
Diarrhea / Constipation
Balance problem
I participate in/do (circle):
prolonged computer work
sports
prolonged postures
sleep face down
What can’t you do right now that is preventing you from fully enjoying your life?
What are your long-term health goals?
Please rate your level of commitment to resolving your problem(s)(10 being the highest): ___
Lifestyle
Habit
None
Light
Moderate
Heavy
Alcohol
Tobacco
Exercise
Sleep
Appetite
please check appropriate box
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
Coffee
For Women Only
Are you pregnant?
Y
N
Date of your last menstrual period:
Are you using any means of contraception?
Y
N
Do you experience severe cramping with your menstrual period? Y
N
Do you suffer from PMS? Y
N
Additional Information
Is there any other pertinent information you would like us to know? Y
N
I give my consent to have the doctor(s) perform an exam and take any x-rays that are deemed
appropriate to better understand my problem and monitor my progress.
Print Name:
Signature:
Date:
(Signature of parent/guardian required if patient under age 18)
Chiropractic On Eagle, Dr. J. Saunders
407 Eagle Street, Newmarket, ON L3Y1K5
905.953.1028

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