HeartLake Chiropractic and Spinal Decompression Centre | Chiropractor Brampton Ontario

What are your chief complaints?
NeckLow BackButtocksHipLegFootToesNeck PainShould PainArm Pain

How long have you had this problem?
Less than a month, 1 - 6months 6 months - 1 yearMore than 1 year

Since the problem began, has it gotten worse?
Yes /No

How would you describe your pain?
DullSharpBurningTinglingShootingNumbnessThrobbing

Has your pain affected your life in a negative way?

Yes / No If yes, please describe

Has it affected your Work?

Yes / No If yes, please describe.

Has it affected your Home Life?

Yes / No If yes, please describe

What are some of the things that you used to do before you had the pain that you like to do again if this was not a the problem?

Do you have a MRI?
Yes /No

What activities aggravate your condition?
WalkingStandingBendingListingLying down

What activities relieves your pain?
WalkingStandinBendinListingLying down

If there is a way to fix your problem so that you would not have to suffer with any it any longer, would you want to?
Yes /No

What is the best time to contact you?
MorningAfternoonEvening

Your Name

Your Phone