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Potrero Chiropractors
A Wellness Center
It Began:
Suddenly
Slowly
It Has Lasted:
Hours
Days
Weeks
Months
Years
Have You Ever Had This Problem Before? If Yes, When? List Doctors Seen For This Problem: 1. Any Treatment Given? 2. Any Treatment Given? 3. Any Treatment Given? Yes No, What Yes No, What Yes No, What
Type of Doctor
Type of Doctor
Any Other Treatment, Self Treatment or Medications For This Problem? If Yes What Type Have You Had Any Changes In: Bowel Bladder or Sexual Function
Yes
No
No
Yes, Explain
What Makes Your Condition Worse? Nothing Standing Sitting Movement Exercise Trying to Stand Other
What Makes Your Condition Better? Nothing Exercise Rest Cold Hot No Loss of Sleep Confusion Headache ( Convulsions Daily Weekly) Bad Moods Medication Other
Do You Have Any Nervous System Complaints? Blurred Vision Depression Numbness Forgetfulness
Potrero Chiropractors
A Wellness Center
Yes
No
Yes
No
Yes
No
Are You Currently Employed? Are You Currently Working? Can You Continue To Work?
Yes Yes
No No
Child Care
Recreation
Other
When Was Your Last Medical Examination? If No, please explain Any Additional Comments You Feel Are Important: