Health History Adult

Address:
BIRTHDAY
Name:
Have you seen a Chiropractor before?
This field is hidden when viewing the form
Headaches?
Pins & needle arms?
Dizziness?
Numbness in fingers?
Fatigue?
Sleeping problems?
Cold Sweats?
Diarrhea?
Mood swings?
Pins and needles legs?
Loss of smell/taste?
Buzzing in ears?
Numbness in toes?
Depression?
TMJ Disorder?
Migraines?
Neck stiffness?
Constipation?
Light sensitivity?
Menstrual pain?
Menstrual irregularity?
Fainting?
Back Pain?
Ringing in ears?
Irritability?
Cold Hands/Feet?
Fever?
Problems urinating?
Neck pain?
Loss of balance?
Nervousness?
Indigestion?
Stomach Upset?
Tension?
Sports Injury?
Auto Accident?
Weight Trouble?
Heartburn?
Ulcers?
Anxiety?
Diabetes?
High Blood Pressure?
Hot Flashes?
Please enter a number from 1 to 10.
Please enter a number from 1 to 10.
New Wave Stress and Pain Relief Logo
CONTACT
174 Saundersville Road, Suite 301,
Hendersonville, TN 37075
PainReliefTN@gmail.com
615.695.7711

Copyright © 2025. New Wave Pain and Stress Relief. All rights reserved.

Website by CGC
Dr Paul Hodgson The Power to Heal Book

ARE YOU SEEKING BETTER HEALTH?

This is the book that explores advanced concepts in healing and is the tool to launch your own healing miracles. Maintain your family’s health without dangerous drugs and risky surgeries.