Health History Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Musculoskeletal IssuesBody Tension/Tightness - Pick your top three regions that you feel body tension or tightness (you can choose 0-3):Skull tensionFace tensionThroat tensionNeck-upper shoulder tensionChest tensionMidback tensionAbdominal tensionLower Back tensionAnterior Pelvis tensionGluteal/Buttock tensionLegs or feet tensionMusculoskeletal problems you want to improve/clear up over the next 3-6 monthsHeadachesFacial painTMJ (jaw) issuesNeck PainShoulder Joint painElbow painWrist issuesHand issuesMidback painLower Back PainPelvis or Hip painSciatica (leg nerve pain)Knee painsFoot pains Health Issues 0= Not a problem for me 1= Have it, no concern 2= Have it, moderate concern 3= Have it, moderate concern - and taking medication(s) 4= Have it, very concerned 5= Have it, very concerned - and taking medication(s) Getting rid of / Improving my: Brain Fog Selected Value: 0 Mental Sluggishness Selected Value: 0 Mental Stress Selected Value: 0 Anxiety/ Nervousness Selected Value: 0 Depressive Mental State Selected Value: 0 Memory Issues Selected Value: 0 Concussion Issues Selected Value: 0 Organic Brain (Parkinson’s, Stroke,…) issues Selected Value: 0 Vertigo Selected Value: 0 Tinnitus Selected Value: 0 Sinus Problems Selected Value: 0 Allergies Selected Value: 0 Thyroid/Adrenal Issues Selected Value: 0 Chronic Fatigue/Tiredness Selected Value: 0 Overweight problems Selected Value: 0 Osteoporosis Selected Value: 0 Immune System weakness Selected Value: 0 Asthma/Lung Issues Selected Value: 0 Stomach – GIRD, reflux, hiatal hernia, ulcers Selected Value: 0 Poor Digestion Selected Value: 0 Gas/Bloating after meals Selected Value: 0 Diabetes/Sugar Cravings Selected Value: 0 High Blood Pressure Selected Value: 0 Heart Issues/High Cholesterol Selected Value: 0 Constipation/Diarrhea Selected Value: 0 Cancer Selected Value: 0 Gallstones/Liver-Gall Bladder issues Selected Value: 0 Kidney, Bladder, UTI issues Selected Value: 0 Feeling of having a toxic body Selected Value: 0 Menstrual/Menopausal/Libido issues Selected Value: 0 Prostate/Libido problems Selected Value: 0 Skin & Hair Problems Selected Value: 0 Chronic tightness meals I also want to … (Check up to 4) *Have more energy/vitalityHave less stress building up in my bodyHave better sleep/wake up refreshedHave a more flexible body/spineKeep my mental faculties as I ageHave better postureImprove my sports performanceMove throughout my day without painHave help in living a long, healthy lifeLearn how to eat healthierLearn more about natural healing/livingBe more mentally-spiritually positivePlease share with Dr. Walsdorf why you are seeking his help at this time. Feel free to share any relevant aspirations and personal goals you have. Please also include any previous treatments and/or self-therapies you have tried. *By submitting this form I recognize that Dr. Howard Walsdorf is not acting as my medical doctor. He is not treating me for any condition, illness or disease but is rather working with me to improve my body’s resiliency. While I do believe that improving my “resiliency quotient” will help me improve my health, I understand that Dr. Walsdorf makes no claim that this will happen. He is, as a holistic chiropractor, advising me on integrating a series of natural and holistic therapies into my life.I have read and I agree with the above statementName *FirstLastDate *Virtual Visit: Patient Deposit *Price: $150.00Stripe Credit Card *Submit
