top of page



Please mark all that conditions below that apply to you.  Place an X things your are experiencing right now;  P for past issues; F for family issue.

Next, if you are currently experiencing pain, indicate your pain level with 1 being the least and 10 the most.  Example:  X  –  5 headaches

_______ headaches                                  _______ migraines                                  _______ vision issues
_______ contact lenses                            _______ hearing problems                    _______ deafness
_______ sinus problems                          _______ dental bridges                          _______ braces
_______ jaw pain/TMJ problems            _______ asthma or lung prob.              _______ constipation
_______ diarrhea                                      _______ hernia                                        _______ birth control/IUD
_______ abdominal/digestive                 _______ muscle/joint pain                    _______ muscle/bone 
_______ numbness/tingling                    _______ arthritis/tendinitis                   _______ cancer/tumors
_______ spinal column disorders           _______ diabetes                                   _______ pregnancy
_______ heart/circulatory issues            _______ sprains or strains                    _______ fatigue
_______ chronic pain                                _______ tension                                     _______ stress
_______ depression                                  _______ sleep difficulties                      _______ blood clots
_______ allergies/ sensitivities                _______ rashes/athletes foot               _______ varicose veins
________ infectious disease                    _______ high/low blood pressure

Please list any other health issues or concerns we should be aware of: 


Please list any surgeries, scars or plates and screws that we need to be aware of:


Please list any accidents.  This includes things as simple as slipping on the ice to more severe accidents.  This information is important to help us discern how to best assist you in your recovery. 


SpiritWay is not a medical institution.  We do not diagnose or treat.  All questions being asked are for informational purposes only. If you have medical or mental health issues please contact your health care professional.

bottom of page