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Online Questionnaire

Complete the confidential on-line questionnaire. This will allow us to assess your needs and recommend a treatment plan especially for you.

IMPORTANT! - Please be aware that the information you provide to us in the form below, as well as any other information you give to us, is collected and reviewed for the sole purpose of providing you with the most thorough and necessary care. We do not share this information with anyone, for any reason. If you have any additional questions about our privacy practices please contact us before completing this form.

To ensure confidentiality, transmission of this application uses encryption technology. To activate this feature on your computer, please click here.

Name: *

Address:

Apt/Suite:

City:

State:

Zip:

Phone:

Email: *

Please indicate the following:

Age:

Height:

Weight:

Has your weight changed in the past 2 years?

Amount of change?

Are you currently being treated for any medical problems?

If yes, please describe the problem(s):

When did this problem begin?

Please list all treatments or tests that you've had for this problem:

Diagnostic Tests (X-Rays, blood tests, etc.)

Treatments (medications, surgery, physical therapy):

Complementary medicine (Massage therapy, chiropractic, etc)

Counseling (and other treatments):

Medical History
Please check all that apply.

Problem	Check	When?	Information/Treatment
Heart Disease
Diabetes
High Blood Pressure
Circulation
Arthritis
Stomach/Intestines
Cancer (type?)
Neurological (type?)
Broken Bones
Back pain
Whiplash Injury
Siatica
Disc Degeneration
Spinal Stenois
Shoulder Pain
Elbow Pain
Knee Pain
Muscle Pain
Fibromyalgia
Carpal Tunnel
Headaches
TMJ Dysfunction
Celiac Disease
Hypoglycemia
Scoliosis
Other

List all past surgeries and dates

List all current medications and supplements you are now taking

Medications		Supplements


List all known allergies (food and other)

Personal History
Rate your answer with 1 meaning "No" or "Never" and 5 meaning "Yes" or "Often"

	no				yes
Do you:	1	2	3	4	5
Exercise regularly
Drink Water
Eat nutritious foods
Smoke
Take drugs
Drink Alcohol
Have trouble sleeping
Feel tired
Get Angry
Feel Stressed
Experience difficulty in relationships
Get Depressed
Have mood swings
Have trouble concentrating
Feel happy
Have a spiritual life
Pray or meditate
Watch TV
Spend time with friends
Want your life to change

How would you like us to help you? (Answer all that apply. Provide as much detail as you wish to share.)

Physical Problems:

Mental Issues:

Emotional Issues:

Spiritual Issues:

Lifestyle Change:

Thank you for taking the time to complete this questionnaire. We will carefully review your information and strive to respond within 48 hours.