Chiropractic Intake Form Page 4
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4EENT
Eye Pain
Muscle and
Neck pain
Joint
Double vision
Low back pain
Ringing in ears
Arm pain
Deafness
Shoulder pain
Nosebleeds
Leg pain
Trouble swallowing
Knee pain
Hoarseness
Foot pain
Sinus infection
Swollen joints
Nasal drainage
Arthritis
Enlarged/tender glands
Fractures
Jaw pain
Women
Painful
menstruation
Hot flashes
Irregular cycle
Cramps or back
pain
Nipple discharge
Vaginal discharge
Breast lumps
Menopause
symptoms
Are you pregnant?
No
On the diagram above please outline the area of your discomfort.
Yes
Date of last period:
Why Chiropractic?
People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain/discomfort (Relief
Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved
(Corrective Care). Your Doctor will weigh your needs and desires when recommending a treatment program.
Please check the type of care desired so we may be guided by your wishes whenever possible:
Relief Care
Corrective Care
Thank-you for taking the time to complete these forms!
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