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Check any of the following symptoms that apply to you:
Back or Neck Pain, Stiffness, Soreness
Headaches
Pain Between the Shoulder Blades
Muscular Spasm and Tightness
Pain, Numbness or Tingling in Extremities
Chronic Pain
Painful Joints
Excess Stress
Dizziness or Loss of Balance
Low Energy and Sluggishness

Over the last 12 months have you been involved in: select all that apply
Auto Injuries
Other Injury
Work Injuries
Sports Injuries
If "Other Injury", please Explain:

How has your health condition impacted your life? i.e. has it prevented you from doing an activity that you previously enjoyed?

What health goals have you set or now would like to set for yourself? check all that apply
To initiate or improve upon a fitness/exercise program
To lose excess body fat
To build extra muscle
To consume a healthier, more nutritious diet
To participate in a preventative health plan to increase overall health and well-being
Other:


Place questions and concerns you would like to ask the doctor here. These questions will be addressed at your initial visit.

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