Health Evaluation

	Back or Neck Pain, Stiffness, Soreness		Chronic Pain
	Headaches		Painful Joints
	Pain between the Shoulder Blades		Excess Stress
	Muscular Spasm and Tightness		Dizziness or Loss of Balance
	Pain, Numbness or Tingling in Extremities		Low Energy and Sluggishness

Over the last 12 months have you been involved in:

select all that apply

	Auto Injuries		Work Injuries
	Sports Injuries		Other Injury

If "Other Injury", please Explain:

How has your health condition impacted your life? i.e. prevented you from doing?

What health goals have you set for yourself recently or would you now like to set?
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.

Complete the area below if you would like us to check your insurance coverage:

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If the information on your health card does not match the above or there is additional information, please include it below	:

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