Neuropathy Patient Paperwork

EDDY CHIROPRACTIC | 19038 Soledad Canyon Rd. Canyon Country, CA 91351

Please correct the errors described below.

Please fill out the application entirely and legibly.

*We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you*



1. In order of importance, list the health problems you are most interested in getting corrected:

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2. Is there a certain time of day any of these problems are better or worse?

3. Is your balance/walking ability affected? If yes, please describe:

4. List approximately how long you have noticed these problems in your life:

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5. Select the things you have used for these problems:

6. What do you think is causing your problem?

7. Name of all doctors you have seen for these problems and treatment you received

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8. Have your symptoms:

9. Is this condition interfering with any of the following?




This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Please give name, address, and office phone number of your primary care physician.

List ALL allergies/sensitivities to medication, food, and other items here:

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List the prescription drugs you are currently taking (or you may attach a list):

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List all nutritional supplements (vitamins, herbs, homeopathics, etc.) as above:

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Patient Quality of Life Survey

Please take several minutes to answer these questions so we can help you get better. (Please check all that apply)

7. What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.). Give 3 examples:

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