chiropractic for kids
Our Process
About us
Testimonials
FAQ
Forms
Contact Us
Schedule An Appointment
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Dr. Jill Strominger
Contact & Location
Business Hours
chiropractic for kids
Our Process
About us
Dr. Jill Strominger
Contact & Location
Business Hours
Testimonials
FAQ
Forms
Contact Us
Schedule An Appointment
Adult Consultation History
Name
*
First Name
Last Name
Your main complaint
*
Any other complaints
How long have you suffered with this problem?
*
What have you tried to do to get rid of this problem that DID NOT work?
*
Have you become discouraged about handling this problem?
*
When your problem is at its worst, how does it make you feel?
*
How does this problem interfere with the following areas of your life?
*
Work, Family, Hobbies, Life
Does handling this problem cause stress for you?
*
What do you do that makes this problem worse?
*
How much older does this make you feel?
*
On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem:
*
What gives you some temporary relief?
*
What is the pattern of this problem?
*
Constant
Intermittent
Occasional
Cyclic
What is the effect it has on your body functions?
*
How did it start?
*
Are you on any type of medication? Please list all:
*
Could your problem have been caused by an injury at work?
*
If yes, please give us the details:
Have you been involved in an auto accident?
*
Date of accident, any difficulties from this?
Do you have any children?
*
Do they have any health problems that you are aware of?
*
Is there any other information you would like us to know?
*
(FOR WOMEN ONLY) Date of your last menstrual period:
MM
DD
YYYY
(FOR WOMEN ONLY) Are using any means of contraception?
(FOR WOMEN ONLY) Do you experience severe cramping with your menstrual period?
(FOR WOMEN ONLY) Do you suffer from PMS?
Thank you!
