Campbell Chiropractor, Campbell CA: Forms

Dr. Robert Asks...

Can those with osteoporosis get chiropractic care?

Of course. When developing a care plan, we consider the unique circumstances of each practice member. There are many ways we can adjust the spine. The chiropractic method we select will be best suited to your age, size and unique situation.

How do most people deal with subluxations?

First, they try to ignore them. When they don't, they go to the medicine cabinet to stop their brain from feeling the symptom. Later, back surgery may be threatened. Sadly, it's not until this later stage that they consult our Campbell chiropractic office. Yet, even with the delay, most are delighted by the results produced by today's chiropractic care. Contact us and let's get started.

Name:
Date:
Address:
City/State/ZIP:
Home Phone:
Work Phone:
Cell:
Birth Date:
Age:
Marital Status:	M W D S
Email Address:
Your Employer:
Occupation:
Spouse's Name:
Spouse's Employer:
Children's Names and Ages:
What is your most important current goal?
Favorite Hobbies or Interests:
Date of Last Chiropractic Adjustment:
Current health concerns/reasons for consulting our office:
Who may we thank for referring you?
Have you had same or similar problem(s) before?
If so, for how long?
Is this the result of an auto or work injury? If so, when?
Father, mother, brother, sister or children with similar problems? If so, who?
Other doctors you have seen for this problem?
Medications you currently take:
Is there any chance you are pregnant?
Have you ever neen diagnosed with cancer? If so, what kind?
Do you have health insurance? Name of Company:
The above information is true and accurate to the best of my knowledge. Patient or gaurdian Signature: Date:

Name:
Date:
Email Address:
# Hours per week currently working:
# Hours per week Spouse currently working:
Check off any of the following symptoms you have experienced in the last 6 months:	Headaches/Migraines Fatigue Pain/Tension/Numbness Neck Legs Shoulders Arms Low Back Hands Insomnia/Sleep Problems Irritability Digestive Trouble Constipation Diarrhea Gas Bloating Sinus Problem/Allergies Menstrual Problems Asthma Bladder Trouble Ringing in Ears Nervousness Dizziness Weight Trouble
Any other symptoms?
Which of the above bothers you the most?
How long have you been bothered by the condition?
Describe how it feels or affects you when is is at its worst.
Does this cause you to be:	Moody Irritable Interrupt Sleep Restricted on Daily Activities Unable to Concentrate
Does this affect your work:	Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long Hours
Does this affect your life:	Lose Patience with Spouse/Children Restricted Household Duties Hinders Ability to Exercise/Participate in Sports Interferes with Ability to Participate in Hobbies or Other Desired Activities
Other:

The Campbell Chiropractor to see - Chiropractor Campbell

Dr. Robert Asks...

New Patient Forms

Part 1

Part 2

Dr. Robert Martines, 151 North 1st Street, Campbell, California | (408) 378-1881

The Campbell Chiropractor to see - Chiropractor Campbell

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Dr. Robert Asks...

New Patient Forms

Part 1

Part 2

Dr. Robert Martines, 151 North 1st Street, Campbell, California | (408) 378-1881