Would you like Dr. Peterson to call you to talk about your health?
yes no

Where do you have pain? Check all that apply.

Headache		Pain betweeen shoulder blades
Neck pain		Low Back pain
Arm pain		Hip pain
Wrist Pain		Leg pain

Are you untreated? no
If untreated does the pain worsen or spread?

What do you feel causes the pain?
write here

What treatment have you had for the problem and how affective
was the treatment?
write here

Have you had Chiropractic treatment before? yes no

What ailments have you had and to what intensity and frequency?
Click for definition of terms:

Headache		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Neck pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Arm pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Wrist pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Pain between shoulder blades		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Low back pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Hip pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10
Leg pain		never occasional inter mittent frequent constant		0 1 2 3 4 5 6 7 8 9 10

If you have comments or questions please enter them here:
write here

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