PATIENT QUESTIONNAIRE

ATLAS DISPLACEMENT COMPLEX

Name ______Age Date ______

Back In Time From the Beginning We Are Asking You Important Questions?

  1. YourBirth Process: (Babies are damagedat birth. G. Guttmann M.D. His extensive X-rays research proved this)

Were you born in a hospital? _____ Was your delivery long/difficult?(over 6 hrs.)______

Forceps Vacuum extraction Breech ______Drug Induced Labor _____C-section

Mother sick during pregnancy? ______

II. From 1 to 18 years of AgePlease Indicate: ONLY DESCRIBE from 1 to 18 Years of AGE

Physical Stressors:

Falls, injuries, accidents of any kind? ______

______

Physical abuse? Parents, siblings, neighbors? ______

Chemical Stressors:

Where you breast fed? Formulae fed? Nutrition as an Infant, Child and Teenager? ______

Medications as an Infant, Child or Teenager? ______

Surgeries as anInfant, Child, or Teenager? ______

Complications: Meds or Surgeries? ______

Exposure to toxins of anykind as Infant, Child or Teenager?______

Mental Stressors:

Mental abuse? Learning disabilities/other problems in school?

III: Adulthood 18 years to Present Please Indicate: ONLY DESCRIBE from 18 yrs to Present Age

Physical Stressors:

Falls, injuries, accidents after 18 yrs of age? ______

______

Auto or Any Vehicles Accidents? ______

______

______

Chemical Stressors:

Nutritional: How would you describe your eating habits? A B C D F ______

Sugar Consumption ? Consumption “fast foods” ______

Excess Alcohol ______Smoke pot?______Drugs ______

Ever smoked? ______# yrs.______

Medications: (OTC or Prescribed) ______

Surgeries: Recommended, Declined or Performed? ______

Exposure to Toxins of any kind after 18yrs of age? ______

Mental Stressors:

Any significant stress going on currently? Yes No Explain: ______

______

______

How well do you sleep? ______How many hrs. on average per night? ______

Do you exercise regularly? Yes No What sports/activities?

Previous Therapies? ______

Previous chiropractic?______Last manipulation on the neck performed? ______

Did they take Precision upper cervicalPre and Post X-Rays? ___yes ____no Nerve Scans? ___yes ___no

Were you taught about Structural Correction? ___yes ___no Corrective Remodeling Care?___yes ___no

Protective Care Once Fixed? ___yes ___no

IV:Review of Current and Historical Symptoms & Conditions:

 Fatigue  Balance/coordination problems Diabetes

 Dizziness/vertigo Concentration problems  High blood pressure

 Insomnia Memory problems Heart disease

 GERD/heartburn/ulcers Allergies Kidney disease

 Nervousness/anxiety Sinus problems Urinary problems

 Depression Frequent colds/flu/sore throats  Sexual dysfunction

 Upset stomach  Headaches Hemorrhoids

 Diarrhea Respiratory problems Cancer:

 Constipation  Circulation problemsother:

 Ringing/buzzing in ears: L R B Arthritis Neck pain

 Mid-back pain Low back pain Stiffness

 Difficulty walking  Pain/numbness/tingling to arms/hands Pain/numb/ting legs/feet

Females: Are You Pregnant? □ YES □ NO Could you possibly be pregnant? □ Yes LMP date ______

STOP FILLING OUT HERE! (Doctor will review with you.)

V: Truly Getting To Know How Each Individual Patient Feels About Honest Expectations of Upper Cervical Care:

Again State Your #1 Health Issue ______

If you were to rate the severity of the problem on a 1 to 10 scale (10 worse) Circle 1 2 3 4 5 6 7 8 9 10 ______

When this health issue is at its worse, how does it make you feel? ______

If your condition were to stay or worsen how wouldyou feel? ______

If you could get see this problemsignificantly improved or resolved, what would your level of commitment be to follow doctor’s recommendations: 1 to 10 Scale (10 highest 1 being the lowest) Circle 1 2 3 4 5 6 7 8 9 10

If as a result of receiving Upper Cervical care in this clinic, I would like to achieve:

□ Temporary Symptom Relief □ More Energy □ Become More Active □ Healthier Body □ Better Quality of Life

IS THERE ANYTHING ELSE YOU THINK I NEED TO KNOW or DOES THAT COVER IT VERY THROUGHLY?

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