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Chief Physical Complaints
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Chief Emotional Complaints
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Please list any other concerns that you would like the doctor to know about:
How do you feel about your current condition? (Please choose ONE that BEST describes how you feel.)
I feel helpless; nothing works.
I don't like what I am feeling, and I hope you can fix it.
I feel this is a pattern that has happened to me before; it is back again.
I feel there is a message my body is giving me.
I am looking for assistance in becoming healthier so I can move past my health concern.
I realize my condition may be a necessary experience in getting to the real problem.
I don't know how I feel. I am too preoccupied with my present condition.
I am looking for something to help me enhance my quality of life and further enhance my wellness.
What would you like to accomplish from your healing process in our office?
Have you ever had your spine or nervous system examined professionally?
Yes
No
Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime?
Never
Once
Twice
A few times
Over 24 times
I lost count and would not live without it
Do you know what type of adjustments the chiropractor performed, or what technique(s) or methods he or she used?
Have you ever received Network Chiropractic / Network Spinal Analysis Care?
Yes
No
Have you had in the past or do you current participate in any of the following vehicles toward health, growth and personal development? (Check all that apply)
Life Coaching
Massage Therapy
Acupuncture
Hypnotherapy
EFT
Meditation
Yoga
Drumming
Energy Medicine
Oneness Blessing
Somato Respiratory Integration (The 12 Stages of Healing)
Osteopathy
Karate/Martial Arts
Dance
Craniosacral Therapy
Homeopathy
Psychotherapy
BIRTH: Were there any problems associated with your mother's pregnancy with you? (Check all that apply)
Outwardly Ill
Trauma
Difficult Pregnancy
Falls, Accidents or Physical Injuries
Unusual Stress
Was your delivery?
At Home
In Hospital
Natural
Drug Induced
C-Section
Breech
Forceps/suction
Prolonged labor
Cord around neck
Traumatic
TRAUMA RELATED MEDICAL INTERVENTIONS: Have you had any of the following? (Check all that apply)
hospitalization
surgery
organ removal
spinal tap
spinal injections
physiotherapy
neck collar
spinal brace
traction
special shoes
orthotics
heel lift
radiation treatments
blood transfusion
corrective shoes or bars on shoes
extensive diagnotstic x-rays
chemotherapy
bone in cast or immobilized
VEHICULAR ACCIDENTS: Have you (even as a passenger and even if you do not think you were hurt) been involved in a collision or near collision? Please check all that apply and state approximate dates and severity (Mild, Moderate, Severe or Extreme).
automobile
motorcycle
bus
train
bicycle
airplane
mo-ped
skateboard
other
OTHER PHYSICAL TRAUMA:
physical fight
armed forces
abuse
knocked unconscious
broken nose
During the day, I:
sit
stand
walk
drive
do desk work
phone work
mechanical work
heavy lifting
BIRTH: During your mother's pregnancy with you did she: (Check all that apply)
use prescription drugs
use non-prescription drugs
chemically induce labor
consume alcohol
smoke
Was your mother:
Conscious
Semiconscious
Unconscious
Under Spinal Anethesia during delivery?
OTHER CHEMICAL STRESSORS:
Have you and your family members been vaccinated?
Yes
No
Do you or have you ever taken:
prescription drugs
over the counter drugs
antibiotics
other
Do you or have you ever worked with:
chemicals
fumes
dust
smoke
Do you consume:
alcohol
coffee/caffeine
tobacco
artificial sweeteners
soda
tap water
recreational drugs
diet food
refined sugar
eggs
cooked, canned vegetables
raw vegetables
fresh fruit
whole grains
dairy
fried foods
beef
poultry
fish
seafood
organic foods
Medications are chemicals that can and may cause subluxations and imbalances in nervous system function. Are you now taking any drug (prescription or over-the-counter) regularly?
If you were previously taking any other medication regularly, please describe:
Were you:
Bottle fed formula
Bottle fed mother's milk
Nursed
Nursed and bottle fed
How do you grade your physical health?
Excellent
Good
Fair
poor
Getting Better
Getting Worse
Rate your emotional / mental health:
Excellent
Good
Fair
poor
Getting Better
Getting Worse
Rate your overall quality of life:
Excellent
Good
Fair
poor
Getting Better
Getting Worse
Please check all that apply and note their severity on a 1-10 scale (1 is the easiest and 10 the most difficult):
Childhood Stress
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Work Related Stress
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School Stress
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Stress of Commuting
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Play or Recreational
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Loss of loved one
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Family Stress
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Change in lifestyle
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Personal Relationships
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Change in vocation
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Stress of being sick
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Abuse
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Divorce / Separation
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Parents divorce
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Financial
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Which are you most interested in?
Crisis and emergency care
Wellness and maintenance care
If we find subluxations in your spine, is there anything that might prevent you from following through with the doctor's recommendations?
If so, please explain:
Research shows that people in care report changes in their physical state, mental emotional states, their body's ability to adapt to stresses, achieve a heightened quality of life and make positive lifestyle choices. Which of these would most excite you to share this work with your friends and family?
If you consider yourself ill, why do you feel you are ill?
If you consider yourself well, why do you feel you are well?
Is there anything else you wish to share, which has not been discussed, that may help us to better understand you and why you have chosen to see the doctor in this office?
Please correct all errors to continue.
You must check the box agreeing with the statement of authorization to proceed.