How did you hear about Wellness Chiropractic?
How serious do you think your problem is?
What is your reason for prompting your request for a consultation with the Doctor?
1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is?
2. What are you hoping happens today as a result of the doctor spending time with you today?
3. Since your back pain became this severe what three things has it caused you to miss the most?
4. How long have you been like this?
5. What chnages/modifications have you had to make and how has your lifestyle change since your back problem?
6. What actions or activities do you have troubles with or are have limitations in?
7. What kinds of treatments have you received?
8. When did you receive these treatments and for how long?
9. Did any of these treatments seem to work in helping your pain? If so which one(s)? For how long?
10. What actions can you take that temporarily decrease the pain?
11. What activities/movements are guaranteed to increase your pain and worsen your condition?
12. What does the pain feel like (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc...) and where?
13. What does it feel like when you wake up compared to the rest of the day? Is it worse in the morning or evening?
14. What do you think will happen to you if you cannot find a solution to your pain/problem?
15. What are you hoping Dr. Thalhamer tells you today?
16. Please express what you hope or imagine his state of the art program and knowledge might be able to accomplish for you?
17. Describe what will be different in your life if you can get better.
18. Please describe in detail the VERY FIRST time you recall having this problem and what it felt like?
List in Order of Importance all OTHER health problems/concerns NOT including your main problem above.
On a scale of 0-10 (10 being unbearable, 0 being no pain or discomfort? Please rate the following...
The HIGHEST your pain gets WITHOUT medication.
The LOWEST your pain gets WITHOUT medication.
The HIGHEST your pain gets WITH medication.
The LOWEST your pain gets WITH medication.
List ANY surgeries that you have had and the corresponding dates.
Medications (list any medications you are taking, and dosages)
Allergies to medications or substances
Please type in name below as acknowledgment to sign.
