Health Evalation
Fill in the form below for a and your data will be sent to the doctor for a free health evaluation
*Fields marked with an are required**
	Name *		Age *	Home Phone *	Cell Phone
	Work Phone		Email
	Street Address *
	City *		State *		ZIP *
	Occupation	# of Hours	Spouse's Occupation		# of Hours
I. Check the box next to the symptoms you have experienced in the last 6 months.
	Low Back Pain	Pain Between the Shoulder Blades			Neck Pain
	Headaches or Tension	Tired or Fatigued			Wrist or Hand Pain
	Elbow Pain	Shoulder Pain			Hip Pain
	Knee Pain	Ankle or Foot Pain			Ringing in Ears
	Allergies	Digestive Troubles			Weight Trouble
	Tension Across the Shoulders	Numbness or Tingling in the Arms or Hands			Numbness or Tingling in the legs or feet
	Dizziness	Nervousness			Difficulty Sleeping
	Which one of the above symptoms is the worst
	How long have you had it
	When it is at its worst how does it feel
II. Check the boxes that represent how you act
	Irritable		Moody
	Interupts Sleep		Restricted on daily activities
III. Check how this affects you at work.
	Decision Making		Poor Attitude
	Exhausted at the end of the day		Unable to work long hours
	Decreased Productivity
IV. Check how this affects your life.
	Lose patience with spouse or children		Hinders ability to exercise or play sports
	Restricted household duties		Interferes with ability to participate in hobbies
	Would you like to get rid of the problem?		Yes No *
	Do you have insurance?		Yes No
	Is it an HMO?		Yes No