Pomeroy Chiropractic Wellness

First Name

Middle Initial

Last Name

Date

Address

City

State

Zip Code

Birthday

Marital Status

Single Married Divorced Widowed

Primary Phone

Other

for Cell Carriers not listed

Email Address

Used for Appointment Reminders & Newsletters

Name of Parent/Guardian

for Patients Under 18

Referred by?

How did you hear about us? (First & Last Name, if applicable)

Main Complaint

Reason for this Visit

When Did This Begin

Approx.

What Activities Aggravate Your Symptoms?

Does this interfere with: Check all that apply.

Work

Sleep

Daily Life

Driving

Sitting

Exercise

Other

Please specify.

Types of Pain: Check all that apply.

Sharp

Dull

Ache

Throb

Spasm

Numb

Tingling

Shooting

Burning

Radiating Symptoms?

How often do you experience these symptoms daily? Check all that apply.

100%

75%

50%

25%

10%

Only with Activity

When Was Your Last Chiropractic Visit? (approx.)

The spine should be checked and maintained from birth.

Have you EVER had any falls, auto collisions, or injuries?

If Yes, Briefly Describe.

Have you EVER had any surgery?

If Yes, Briefly Describe.

Do you take prescription medications? PLEASE LIST:

Do you take over the counter medications? PLEASE LIST:

Do you take vitamins/supplements? PLEASE LIST:

In addition to your Main Complaint, what Health Goals do you have for your future?

Chiropractic is the science of locating and the art of correcting subluxations without the use of drugs or surgery and the philosophy that the body can heal itself when the nerve system is functioning properly. We do not treat pain nor do we diagnose disease here.

We detect and correct subluxations to keep you, your family, and our community healthy.

There are six kinds of disturbances that can affect the human body: GLANDULAR, ELIMINATIVE, NERVOUS, DIGESTIVE, MUSCULAR, AND CIRCULATORY. All dis-eased conditions, illness, aches & pains, and other discomforts experienced by the body can be attributed to one or more of the above disturbances to the body's 6 systems or "ZONES".

We use the Zone Technique to identify and then correct with a specific adjustment to create 100% function.

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