Health Appraisal

We are interested in getting to know you, and any health issues you may be experiencing. Please take a moment to complete our health appraisal. We will be happy to contact you to discuss ways we can assist you in maintaining and improving your health.

Name:
Phone Number:
E-mail:
Address:
City:
State:
Zip:
Age:
Gender: (M or F)
Occupation:

To best assess your current health, please indicate any symptoms you have experienced in the past six months.
	Headache/Migraines
	Sinus Problems
	Dizziness
	Sleep Difficulties
	Neck Pain
	Pain Between the Shoulders
	Lower Back Pain
	Depression
Pain or numbness in the following:
	Arms Legs Hands
	Tired When You Wake Up
	Breathing Problems/Asthma
	Menstrual Pain
How long has it been since you started with the symptoms?
	Less than 6 weeks
	More than 6 weeks
Overall intensity of your health problems:
	Minimal Moderate Severe
Do your complaints interfere with your normal daily activities (work, family, sports)?
	Yes No
If this health issue went without being taken care of, would it effect you to a greater extent?
	Yes No
Have you ever had an auto accident or work injury?
	Yes No
If you could afford to regain your health and wellness, would you be willing to do whatever it takes at this time in your life?
	Yes No
Would you like the office to call you to schedule a NO COST consultation and exam?
	Yes No
If yes, what is the best time to reach you?
	Morning Afternoon Evening
If you have any questions, we would be happy to talk to you about your current state of health. Please feel free to submit your question(s) in the area provided below and we will respond to you via email, or call you if you have selected to be contacted above.