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Personal Information - Edgewood Holistic Chiropractic Center, PLLC

Date Today

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Address *

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Weight

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Emergency contact

Emergency contact Phone

How did you hear about us?

WHAT BROUGHT YOU INTO THIS OFFICE:
If you have no symptoms or complaints and are here for Optimal Health & Wellness Services, please skip to the “General Health History”.

Health Concerns - Please list your health concerns according to their severity

1. Health Concern

Rate of severity

Please choose

1 = mild
2
3
4
5
6
7
8
9
10 = severe
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When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

2. Health Concern

Rate of severity

Please choose

1 = mild
2
3
4
5
6
7
8
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

When did this episode start?

If you had this condition before, when?

Did the problem begin with an injury?

Yes

No

% of the time pain/symptom present

3. Health Concern

Rate of severity

Please choose

1 = mild
2
3
4
5
6
7
2
9
10 = severe
No elements found. Consider changing the search query.
List is empty.

If you had this condition before, when?

When did this episode start?

Did the problem begin with an injury?

Yes

No

% of time pain/symptom present

Did your symptoms start suddenly or progressively?

What were you doing when your symptoms started?

Since it began, is it:

About the same?

Better?

Worse?

Provocation/Palliation

What makes it worse?

What makes it better?

Quality

How would you describe your symptoms? Dull? Sharp? Ache? Etc

Region/Radiation

Where do you feel the symptoms? Does it radiate?

What have you done to help this condition? Was it of benefit?

Do you have a family history of this or similar symptoms?

Other doctors you have seen for this condition:

Basic Chiropractor (focuses mainly on neck and back pain)

“Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)

Medical Doctor

Dentist

Other

Doctor's details

Name

Address

When did you see them?

What did they say wrong?

Did it help?

Yes

No

What did they do?

Please describe

Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.)

Yes

No

If yes, What?

Is this condition interfering with any of the following:

Work

Sleep

Daily routine

Sports/exercise

Other

If other, please eaxplin

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Begin the JourneyStart Here

YouTube Channel

© 2025 Edgewood Holistic Chiropractic Center, PLLC - All Rights Reserved

Terms & Conditions