Spectrum Health Center, Health Evaluation Chiropractor in San Jose

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

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. prevented you from doing?

What health goals have you set for yourself recently or would you now like to set? 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.

Give us some information about yourself.
*	Name:
	Street Address:
*	City:		* State		Zip:
*	E-Mail:
*	Telephone:
*	Date of Birth:			male female

	How Should We Contact You? Home Telephone Work Telephone E-Mail

	Rate Our Site:	Extremely Useful Very Useful Slightly Useful Not Useful

* required information