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"The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease."

- Thomas Edison

HEALTH EVALUATION

Check any of the following symptoms that apply to you:

Back or Neck Pain, Stiffness, Soreness
Headaches
Pain Between the Shoulder Blades
Muscular Spasm and Tightness
Pain, Numbness or Tingling in Extremities

Chronic Pain
Painful Joints
Excess Stress
Dizziness or Loss of Balance
Low Energy and Sluggishness

Over the last 12 months have you been involved in:(select all that apply)

Auto Injuries Other Injury Work Injuries Sports Injuries

If "Other Injury", please Explain:

How has your health condition impacted your life?i.e. has it prevented you from doing an activity that you previously enjoyed?

What health goals have you set or now would like to set for yourself? check all that apply

To initiate or improve upon a fitness/exercise program
To lose excess body fat
To build extra muscle
To consume a healthier, more nutritious diet
To participate in a preventative health plan to increase overall health and well-being
Other:

Place questions and concerns you would like to ask the doctor here.

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312.337.4004

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