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.