Instructions: Type the information in each field.
You can move to the next item by using the TAB key or clicking in the field.
When completed, click SUBMIT.
 
 
 
 
 
 
 
 
 
 
 
Do you grind your teeth or have TMJ?
Do you sleep well?
Do you smoke?
Are you pregnant?
Due date
Please list current medications, if any, and their purpose.
Have you had surgery in the past few years?

What physical routines do you follow per week?

Weights Gym Pilates
Yoga Gyrotonics Other

 

Please check any of the following that have applied to you:

Arthritis Headaches Edema
Broken bones Bursitis Diarrhea
Neck pain Skin disorders Sinusitis
Varicose veins Back pain Sciatica
Heart condition Chest pains Abdominal hernia
Low blood pressure P.M.S. Ringing ears
High blood pressure Herniated disc Fainting spells
Shortness of breath Extremity numbness Loss of balance
Severe menstrual pain Cancer Blood clots
Dizziness Diabetes Constipation
     
     

All information is confidential, unless an authorization for release of information is requested by the client.