Health Assessment
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This survey has been designed to provide our doctors a brief description of your health related concerns.  It is intended to open a dialogue between you and the doctor.  Often times many of these conditions can be resolved through chiropractic care, in addition to improving your state of wellness.  Perhaps you are suffering needlessly.

Have you been suffering from any of the following? (select all that apply)

Fatigue Ankle/Foot Pain Pain Between Shoulder Blades
Dizziness Wrist/Hand Pain Numbness/Tingling in Arms/Hands
Shoulder Pain Loss of Grip Strength Numbness/Tingling in Legs/Feet
Headaches Burning in Arms/Legs Difficulty Sleeping
Neck Pain/Stiffness Tension Across Shoulders Low Back/Hip Pain
Knee Pain Digestive Disturbances Other 

How long have you been bothered by this condition? (select one)


How often do you experience this problem? (select one)


Is this condition affecting your lifestyle in any way? (select one)


If you answered yes to question #4, how does it affect you? (select all that apply)

Moodiness Restricted Daily Activities Hindered Ability to Exercise
Decision Making Poor Attitude Unable to Work Long Hours
Irritability Interrupted Sleep Interferes with Desired Activities
Exhaustion Decreased Productivity Interferes with Hobbies
Lack of Patience Restricted Household Duties Other 

What other healthcare professionals have you seen? (select all that apply)

Family Doctor Chiropractor Massage Therapist
Orthopedist Physical Therapist Nutritionist
Neurologist Acupuncturist Other  

What medications do you currently take relating to this condition? (select all that apply)

Aspirin or similar Pain Killers
Anti-inflammatory Other 
Muscle Relaxants

Would you like to get rid of your problem? (select one)

Please provide the following contact information:

Name  
Street Address  
Address (cont.)  
City  
State/Province  
Zip/Postal Code  
Work Phone  
Home Phone  
E-mail  
Age  
Sex Male Female

Would you like to be contacted to schedule appointment?

Best time to contact me:   

 

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Copyright © 2004  Dr. Ronald A. Weinstein. All rights reserved.