CHIROPRACTIC HEALTH QUESTIONNAIRE Symptoms related to the Nervous System Interference Chiropractic deals with the relationship between your spine and nervous system. The Nervous System’s function is to control and coordinate all the other organs and structures. Pinched or irritated nerves may interfere with this function and thus cause a wide variety of symptoms. Chiropractors call these Vertebral Subluxations. There are 3 basic components: • Misalignment (like tires on your car out of alignment, spinal misalignments are visualized on weight bearing x-rays). • Fixation of spinal vertebra (stuck or locked) • Nerve Interference (like a plugged valve in a drip irrigation system, water does not get to the plant and it slowly dies). Eye/Vision Disorders Ear Infections and/or Hearing Disorders High Blood Pressure Loss of Taste Sinus Trouble Headaches and/or Migraines Thyroid Disorders and/or Fatigue Nervousness/Anxiety Insomnia and/or Sleep Disorders Dizziness and/or Vertigo Loss of Smell Radiation Arm Pain and/or Numbness Reoccurring Sore Throats Asthma and/or Difficulty Breathing Chronic Cough Stomach Discomfort and/or Acid Reflux Digestive Disorders and/or Irritable Bowel Nausea Gout and/or Kidney Disorders Gall Bladder Problems Allergies and/or Adrenal Problems Constipation and/or Diarrhea Abdominal Pain Hemorrhoids Urinary Disorders Menstrual Disorders and/or PMS Numbness and/or Pain in Legs Miscarriages and/or Infertility Prostate Problems Past Present No
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CHIROPRACTICHEALTH QUESTIONNAIRE
Symptoms related to the Nervous System InterferenceChiropractic deals with the relationship between your spine and nervous system. The Nervous System’s function is to control and coordinate all the other organs and structures. Pinched or irritated nerves may interfere with this function and thus cause a wide variety of symptoms.
Chiropractors call these Vertebral Subluxations. There are 3 basic components:• Misalignment (like tires on your car out of alignment, spinal misalignments are visualized on weight bearing x-rays).• Fixation of spinal vertebra (stuck or locked)• Nerve Interference (like a plugged valve in a drip irrigation system, water does not get to the plant and it slowly dies).
Are you pregnant? ¨ Yes ¨ NoIf yes, when is your due date? ________Are you nursing? ¨ Yes ¨ NoAre you taking birth control?Do You:Experience painful periods? ¨ Yes ¨ NoHave irregular cycles? ¨ Yes ¨ NoHave breast implants? ¨ Yes ¨ No
CHIROPRACTIC EXPERIENCE, continued
smoking status: Everyday / Occasional / Former / Never alcohol status: Everyday / Occasional / Never
Do you exercise regularly? ¨ Y ¨ N / What % of Diet is Vegetables? _______ Do you wear heel lifts? ¨ Y ¨ N / Orthotics? ¨ Y ¨ N
are you interested in taking an active role in your recovery? ¨ Y ¨ N
WERE yOu AWARE THAT:
Doctors of Chiropractic work with the Nerve System? ¨ Y ¨ N
The Nerve System controls all bodily functions and systems? ¨ Y ¨ N
Chiropractic is the largest natural healing profession in the world? ¨ Y ¨ N
Race: American Indian or Alaskan Native / Asian / Black or African American / Caucasian / Hawaiian or Pacific Islander / Other / Decline
¨ I choose to decline receipt of my clinical summary after every visit. (These are often blank as a result of the nature and frequency of chiropractic care).
GOAlS FOR yOuR CARE
¨ Relief Care: Symptomatic relief of pain or discomfort.
¨ Corrective Care: Correcting and relieving the cause of the problem as well as the symptom.
¨ Comprehensive Care: Bring whatever is NOT Working in the body to the highest state of health possible with Chiropractic care.
¨ The Doctor should select the type of care appropriate for my condition.
HEAlTH CONDITIONS
(Please check each of the diseases or conditions that you now have or have had in the past. While they may seem unrelated to the purpose
of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care).