Name: Home Phone: Address: Work Phone: City, State, Zip: Cell Phone: Birth Date: E-mail Address: 1) Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime?: Never: 2) When was your last complete spinal examination including x-rays? : Never: 3) Spinal misalignments cause decay and degeneration which results in grinding or cracking . Do you ever hear noises when you move your head or neck?: Yes No 4) Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture? 1=Poor, 10=Excellent: 1 2 3 4 5 6 7 8 9 10 5) Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days. 1=Poor, 10=Excellent: 1 2 3 4 5 6 7 8 9 10 6) Please list any health symptoms or health complaints you are experiencing.1: 2: 3: 7) Prescription medications may cause various side effects, hide the severity of health problems and hinder the body’s ability to heal. What medications are you currently taking?: 8) Auto and work related injuries can cause serious spinal problems. Is this visit related to an accident or injury?: Yes No Date Of Incident: 9) If the doctor feels that your child will benefit from chiropractic care are you willing to follow his/ her recommendations?: Yes No 10) Would you like Dr. Kaler to personally contact you?: Yes No