Bruce Street Family Chiropractic
81 Bruce St.
Kitchener, ON N2B 1Y7
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:
your ability to work
family or social time
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)
Please check any body signals that have been present in the last 12 - 18 months...
low back pain
pain between shoulders
pain or weakness
cold hands or feet
Cancel Form Entry