It has been a while since your last visit and we want to make sure that we are up to date on your health and wellness needs. Please take a moment to complete this short questionnaire so that we can update our files.
My contact information has not changed since my last visit:
False (if false, please provide updated information below)
Street Address Line 2
State / Province
Postal / Zip Code
WHAT IS THE REASON FOR YOUR RETURN AT THE CLINIC?
Where is/are the problem(s)? Please use the lines below to explain.
How long has this been going on?
When did this incident occur?
Is this related to:
Do you have:
Is your pain:
Are your symptoms affected by:
Do your symptoms interfere with:
Hobbies and leisure activities
On a scale of 1-10 (1 = least, 10 = most), please rate the severity of your symptoms
1 is Least, 10 is Most
Do you get headaches?
Are you receiving care from any other health professionals?
If yes, please name them and their speciality:
GENERAL HEALTH HISTORY
Past injuries can affect present health.
Please check all that apply:
If you answered Yes to any of the above, please describe:
Please list any medications you are taking and the reason for the medication:
Please list any vitamins or supplements that you are taking:
Do you wear orthotics or heal lifts?
Have you ever had X-rays taken of your:
If yes, please tell us where and when these X-rays were taken:
Do you have any other health concerns we should know about?
If Yes, please describe:
NERVOUS SYSTEM REVIEW
Your central nervous system (brain and spinal cord) is the master controller of your body. It controls the function of every cell, tissue, and organ. The connection between your brain and your body is through the spinal nerves: sensory, motor, and autonomic nerves. Please review the following system to determine if there may be a connection between your health profile and your nerve interference.
Ringing in the ears
Inner ear problems
Upper Thoracic Nerves
Pain over Heart
High Blood pressure
Numbness in hands
Gall Bladder attacks
Intolerance to fatty foods
Mid Thoracic Nerves
Lower Thoracic Nerves
Digestive complaints after eating
Testicular or ovarian problems
Dizziness upon standing
Dark circles under eyes
Have there been any other changes to your health that we should know about?
If Yes, please describe:
If you had a magic wand, what 3 health conditions or issues would you like to improve upon?
Thank you for filling out our Chiropractic Welcome Back Health Questionnaire. We look forward to helping you with your health concerns and overall well-being!
The Team at Santé Chiropractic and Wellness Centre
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