Also include additional health history information such as heart disease, high blood pressure, diabetes, cancer, etc.

Please fill out this form for to share with the clinic:

Questions? Call: .

Issues

Issue	Started	Better/Worse	Testing/Treatments	Maximum Improvement

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What is the issue (pain/symptom/condition) for which you are seeking treatment?

How did the issue first start?

When did it start?

What makes your issue better?

What makes your issue worse?

What testing or imaging have you had for this issue?

What treatments have you had for this issue? Were they helpful?

Add any additional notes about this issue.

When did you reach maximum improvement with this issue?

Type in a percentage of your recovery from this issue (100% is a full recovery). List any continued deficits.

New Patient Issues