Bruce Street Family Chiropractic
81 Bruce St.
Kitchener, ON N2B 1Y7
(519) 743-6339
info@bsfc.ca
Symptoms
Personal Info
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
hobbies/sports
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?
yes
no
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)
0
1
2
3
4
5
6
7
8
9
10
Very Low
Very High
Please check any body signals that have been present in the last 12 - 18 months...
Musc.Skel.Code
neck pain/stiffness
low back pain
pain between shoulders
pain or weakness
cold hands or feet
arthritis/swollen joints/bursitis
spinal curvature
walking problems
jaw problems
Imm. Code
fever
frequent colds
bronchitis/pneumonia
sinus problems
asthma
allergies
ear infection/tonsillitis
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