Symptom Medications Name First Last Email Are you pain free?YesNoActivities of LifePlease identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:No EffectPainful(can do)Painful (limits)Unable to PreformCarrying GroceriesSit to StandClimbing StairsPet CareDrivingExtended Computer UseHousehold ChoresLifting ChildrenReading/ConcentrationDressingShavingSexual ActivitiesSleepStatic SittingStatic StandingYard WorkWalkingWashing/BathingSweeping/VacuuumingDishesLaundryGarbageClimbing StepsLifting GroceriesIssuesPlease mark P for in the Past, C for Currently have and N for NeverPastCurrentlyNeverheadachePregnant (now)DizzinessProstate ProblemsUlcersNeck PainFrequent Cods/FluLoss of balanceImpotence/Sexual Dysfun.HearburnJaw Pain, TMJConvulsions/EpilepsyFaintingDigestive ProblemHeart ProblemShoulder PainTremorsDouble VisionColon TroubleHigh Blood PressureUpper Back PainChest PainBlurred VisionDiarrhea/ConstipationLow Blood PresureMid Back PainPain w/Cough/SneezeRinging in EarsMenopausal ProblemsAsthmaLow Back PainFoot or Knee ProblemsHearing LossMenstral ProblemsDifficulty BreathingHip PainSinus/Drainage ProblemDepressionPMSLung ProblemsBack CurvatureSwollen/Painful JointsIrritableBed WettingKidney TroubleScoliosisSkin ProblemsMood ChangesLearning DisablityGall Bladder TroubleNumb/Tingling arms, hands fingersADD/ADHDEating DisorderLiver TroubleNumb/Tingling legs, feet, toesAllergiesTrouble SleepingHepatitis (A,B,C)List Prescription & Non-Prescription drugs you takeREGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures: I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Caring Hands Mobile Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. Patient or Authorized person's signatureType signatureDate MM DD YYYY NameThis field is for validation purposes and should be left unchanged.