Name * First Name Last Name Email * Date of Birth * Reason For Visit * When did it start? How did this condition first begin? * What makes it Better? What makes it Worse? * Describe the Symptoms? * Aching Burning Deep Dull Sharp Numbness / Tingling Have you received treatment for this complaint? * Have you seen a Chiropractor / Physical Therapist before? * What was your experience like? Health History Please Check if you have been diagnosed with any of the following: Diabetes Heart Disease High Blood Pressure Auto Immune Disease Arthritis Stroke Cancer Osteoporosis Exercise Frequency * 1-2 X per week 3-5 X per week 6-7 X per week None What type of Exercise do you perform? Please note if you have any difficulties with your exercise program or any specific training goals Thank you! Contact Contact Name * First Name Last Name Email * Subject * Message * Thank you!
