Personal Health

Personal Health

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Present problem/reason for your visit today (be brief):

Please list your health issues/pains starting with your most severe

How bad is it

1=Mild 10=Worst

When did this episode start?

If you have had this condition before, when?

Did the problem begin with an injury?

Often accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this history as it will help us to help you!

Have you had any surgery? (please include all surgery)

Type

When

Doctor

Accidents and/or injuries: auto, work-related, other? (Especially those related to your current problems)

Type

When?

Hospitalised?

 

Stressors: Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category:

On a scale of 1-10 (1 = very low & 10 = extremely high) please grade your present levels of stress (including Physical, bio-chemical and psychological or mental/emotional)

At work:

At home: 

At play: 

 

I consent to a professional and complete chiropractic examination and to any radiographic examination that the Doctor deems necessary.

Personal Health Copy

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  • 1920
  • 1921
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  • 1924
  • 1925
  • 1926
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  • 1928
  • 1929
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  • Day
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  • Year
  • 1920
  • 1921
  • 1922
  • 1923
  • 1924
  • 1925
  • 1926
  • 1927
  • 1928
  • 1929
  • 1930
  • 1931
  • 1932
  • 1933
  • 1934
  • 1935
  • 1936
  • 1937
  • 1938
  • 1939
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  • 1946
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  • 1949
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  • 1952
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  • 1954
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  • 1975
  • 1976
  • 1977
  • 1978
  • 1979
  • 1980
  • 1981
  • 1982
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  • 1986
  • 1987
  • 1988
  • 1989
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  • 1991
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  • 2028
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  • 2030
  • 2031
  • 2032
  • 2033
  • 2034
  • 2035
  • 2036
  • 2037
  • 2038
  • 2039
  • 2040

Often accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this history as it will help us to help you!

Have you had any surgery? (please include all surgery)

Accidents and/or injuries: auto, work-related, other? (Especially those related to your current problems)

Stressors: Because accumulation of stress affects our health and ability to heal, please list your top three stresses (you have ever had) in each category:

I consent to a professional and complete chiropractic examination and to any radiographic examination that the Doctor deems necessary.

Ready to Make a Change?

Contact us today for more information