Bruce Street Family Chiropractic
81 Bruce St.
Kitchener, ON N2B 1Y7
(519) 743-6339
erika@brucestreetfamilychiropractic.com
SYMPTOMS AND ILL HEALTH (PRESENT STATE OF ILL HEALTH)
Years of uncorrected injury or damage show up as acute or chronic symptoms or health problems.
Main purpose for this appointment:
Have you tried anything to ease this problem?
At its worst this problem interferes with:
If you don’t get this problem corrected, do you think it will get worse in the next 5 - 10 years?
On a scale of 1 to 10 (10 being the highest) what is your commitment to getting this problem corrected and improving your health? (Circle)

Very Low
Very High
Please check any body signals that have been present in the last 12 - 18 months...
Musc.Skel.Code
Imm. Code