Chiropractic Appointment Reminder Letter Template Page 7
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9COMPLETE CHIROPRACTIC & BODYWORK THERAPIES
PATIENT/CLIENT COMPLAINT/SYMPTOM FORM
Date: ________________Name: ___________________________________________________
Height______Weight__________
Numbness
= = =
Dull Ache
OOO
Burning
XXX
Sharp/Shooting / / /
Pins/Needles
+ + +
Other
^ ^ ^
Please state your chief complaint:
______________________________________________________________________________
______________________________________________________________________________
How long have you had the symptoms?
______________________________________________________________________________
How did the condition begin?
______________________________________________________________________________
How long did the symptoms last?
______________________________________________________________________________
What makes it worse?
______________________________________________________________________________
What makes it better?
______________________________________________________________________________
How would you describe your pain on a scale of 1 to 10? Circle or write down for each complaint:
(0 is none – 10 is severe)
0
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9
10
_____________________________________________________________________________________
_____________________________________________________________________________________
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