Patient Information

MAJOR HEALTH CHALLENGE:

NAME:

HOW LONG HAVE YOU HAD IT:

TREATMENT RECEIVED:

WHAT CAUSED IT:

OTHER HEALTH CONDITIONS:

HEAD INJURIES: (DESCRIBE INCIDENT AND DATE)

BIRTH PROCESS:

FALLS WHEN LEARNING TO WALK:

FALLS FROM CHANGING TABLE OR BED:

HITTING HEAD ON COFFEE TABLE OR FLOOR:

CHILDHOOD ACCIDENTS:

SPORT INJURIES:

CAR ACCIDENTS:

INDUSTRIAL ACCIDENTS:

PHYSICAL ABUSE:

LIST OTHER FALLS: (HORSE, SNOWMOBILE, SLIP ON ICE, ETC.)

WHAT THINGS DO YOU DO ON A REGULAR BASIS FOR YOUR HEALTH?

EXERCISE:

VITAMINS:

CLEANSING:

OTHER:

SLEEPING POSITION:

STOMACH

SIDE

BACK

SEATING POSITION:

SLOUCHED

LEGS CROSSED

ERECT

DIET

BLOOD TYPE:

HOW MUCH DO YOU EAT OR DRINK OF THE FOLLOWING FOODS PER DAY?

FRUIT:

VEGETABLES:

RED MEAT:

FIBER:

FAT:

MILK:

COFFEE:

TEA REGULAR:

TEA HERBAL:

SUGAR:

SALT:

WHITE FLOUR:

PER DAY:

CIGARETTES PACKS PER DAY:

SODASDIET SODAS:

TYPE & AMOUNT:

DESCRIBE A TYPICAL DAYS MENU:

BREAKFAST:

LUNCH:

DINNER:

SNACKS:

We at Cook Chiropractic Center have an extremely effective weight loss and optimal health program. Are you interested in hearing about our program?

YES

MAYBE

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