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Call: 585-670-0020

Presentations
About
Services
Contact

Presentations
About
Services
Contact
Weight Loss
Chiropractic
Decompression
Education
- Orthotics
- Our Blog
Neuropathy
Forms
MLS Laser Therapy

Presentations
About
Services
Contact

Presentations
About
Services
Contact
Weight Loss
Chiropractic
Decompression
Education
- Orthotics
- Our Blog
Neuropathy
Forms
MLS Laser Therapy

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Patient Trauma History

Patient Trauma History

Most patients have had dozens of IMPACTS throughout their life that could cause SUBLUXATIONS (spinal misalignments). The doctor wants to discover at least 5 of yours. List below any auto accidents, work, home, sports injuries, or falls.

Name

When was your most recent/most significant accident?

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

Any previous auto accidents?

Yes

No

If yes, date

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

When was your most recent/most significant work injury?

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

Any previous work injuries?

Yes

No

If yes, date

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

When was your most recent sports/recreational injury?

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

Any previous sports/recreational injuries?

Yes

No

If yes, date

Briefly Describe

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

Please list any other important traumas (i.e. childhood traumas, illnesses, fractures, sprains, surgeries) not mentioned and date:

Briefly Describe Trauma

Any treatment received?

Yes

No

Describe

Chiropractic care?

Yes

No

Quality of Life Ratings

Subluxations affect our quality of life in many ways. Please enter the number between 0-10 (0 = none, 10 = worst imaginable) that best represents how you rate your quality of life and lifestyle habits.

Sleep Disturbance (0 = none, 10 = worst imaginable)

Stress (0 = none, 10 = worst imaginable)

Fatigue (0 = none, 10 = worst imaginable)

Movement Problems (eg. Getting out of a chair, getting out of bed, walking with ease)

Diet (0 = organic, fruits & veggies, water; 10 = all processed, junk food or fast food, soda)

Focus/Concentration/Memory Issues (0 = no problems, 10 = severe problems)

On average how many days per week you exercise

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For answers to questions about our clinic, treatment options or scheduling an appointment, call Riddle Chiropractic in Rochester today at 585-670-0020.

You can email us too if that’s more convenient, just drop us a line through our secure contact page.

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Dr Riddle Office

Riddle Chiropractic
435 West Commercial St
Suite 4
East Rochester NY, 14445

Phone: (585) 670-0020

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