How did you find out About our Office?
Driver's License #
Social Security #
How Many Children
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Do you have insurance?
Name & Number of Emergency Contact
What problem can We Care Chiropractic best help you with?
When did the problem(s) first begin (even if it has been on and off for a while)?
Condition(s) ever been treated by anyone in the past
What type of practitioner?
What were the results?
How many chiropractic visits have you had in a lifetime?
Do you feel the problem was actually getting fixed or was the care more just relief?
What surgeries have you had?
What activities do you LOVE doing, what is fun for you?
What do you want to change about your life?
How would you rate your mental/emotional stress like family, relationships, children, spouse, work, co-workers etc... on a scale 1-10 (10 means worrying often?
What are the sources of this stress?
How much unhealthy foods do you eat 0-10 (10= sugars, fast foods, breads, pastas, sweets)?
How often do you use tobacco products 0-10 (10=daily)?
How often do you use alcohol products 0-10 (10=daily)?
Please list any medication(s) you currently take (prescription and non prescription)
What condition is it treating?
How much quiet time, relaxing, naps do you typically have in a week?
How often do you usually get checked by your chiropractor?
How much IUs of vitamin D3 do you take and how often?
How much healthy Omega Fats (fish oil, flax oil, coconut oil) do you take?
Do you take a multi vitamin and mineral?
Do you take probiotics and how powerful of dose?
What does your spiritual life look like?
How many days per week do you average working out in the last 90 days?
How much healthy foods do you eat 0-10 (10=lots of good fats, vegetables, fruits, grass fed meat, game etc)?
Please list all other supplements (whey protein) and/or vitamins that you take
Jaw Pain, TMJ
Upper Back Pain
Mid Back Pain
Low Back Pain
Numb/Tingling arms, hands, fingers
Numb/Tingling legs, feet, toes
Foot or Knee Problems
Loss of Balance
High Blood Pressure
Low Blood Pressure
Gall Bladder Trouble