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Search for:
Home
The Treatment
Conditions Treated/Testimonials
Nasal Specifics Video Testimonials
Nasal Specifics Reviews
Doctor Testimonials
Sinusitis/Allergies
Headache/Migraines
TBI/Concussion
Hearing Loss
Autism
Down’s Syndrome
Eye Problems
FAQ
Blog / Case Studies
New Patient Forms
Nutrition Consultation
My Simple Nutritional Message
Testimonials
Subscribe to Dr. Siegfried’s Wholefood Nutrition Newsletter
Forms
7-Day Weight Loss, Cleanse & Detox
Doctor Testimonials
El Tratamiento Nasal
Testimonios en Español
Nasal Specific Intake Forms
Nasal Specific Intake Forms
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2021-10-25T21:34:49+00:00
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Please check the boxes that indicate your current complaint(s) and/or symptoms:
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PainUpper-Back
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PainLow-Back
PainHip-Pelvis Pain
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My Symptoms are due to:
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When did your symptoms beginClick me to edit...
Have you had this complaint before?
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How does this affect your daily life
Are you taking any medications
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If yes for what condition(s)
Are you under care for any other conditions
Any serious condition the doctor should be aware of
Do you have any root canals
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No
If yes, what kind
Mercury fillings
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What kind of water do you drink
Tap
Bottled
Filtered
Well
Spring
Sitilled
All of the above
*Females Are you pregnant at this time
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Due Date
Do you wear arch supports
Yes
No
If yes, what kind
PAST HEALTH HISTORY:
Please list any surgeries you have had and when
Previous Trauma/Injury: Head, back, neck, other:
Have you ever broken any bones
Which ones
Known allergies
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FAMILY HEALTH HISTORY:
Back problems:
Scoliosis:
Check all that apply:
Cancer
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Headaches
Heart disease
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Heart problems below age 40
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SOCIAL HISTORY:
How many hours a week do you work?
Do you play sports
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If yes, which exercises
Any trouble sleeping
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If yes, how any hours a night
Do you drink alcohol
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Do you smoke
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PATIENT HEALTH HISTORY WORKSHEET:
What time of the day are your symptoms better
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What time of the day are your symptoms worse
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ACTIVITIES OF DAILY LIVING (ADL) WORKHSEET
(Please check the number which most closely describes your "Activities Of Daily Living" today)
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2. Frequency of Pain:
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3. Personal Care (Washing, Dressing, Etc.):
1
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4. Travel (Driving, Riding, etc.):
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5. Work:
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6. Recreation:
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7. Sleeping:
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8. Lifting:
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9. Walking:
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10. Standing:
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REVIEW OF SYSTEMS
Have you had any of the following pulmonary (lung-related) issues?
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Have you had any of the following cardiovascular (heart-related) issues or procedures?
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Pacemaker
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Have you had any of the following neurological (nerve-related) issues?
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One-sided Weakness of Face/Body
History of Seizures
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Have you had any of the following endocrine (glandular/hormonal) related issues or procedures?
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Have you ever had any of the following hematological (blood-related) issues?
Anemia
Regular anti-inflammatory use(Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve)
HIV Positive
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None of the Above
If other, please indicate which one:
Have you had any of the following musculoskeletal (bone/muscle-related) issues?
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