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Chiropractic
Examination Forms |
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First Appointment
Instructions
Please try to arrive a few minutes before your
scheduled appointment time. Paperwork must
be completely filled out
prior to coming in, or we will have to
reschedule your appointment, which can take up to 2
weeks.
If you need to reschedule, we require at least 24
hours notice. Comprehensive wellness examinations
can be rescheduled once at no charge, after which
there is a cancellation charge. You may still have
to wait a few minutes upon arrival before the doctor
can begin your examination. Still be here at your
scheduled time.
Please do not consume any caffeine for at least
four hours prior to the
examination, it distorts the exam findings. Thank
you. We look forward to seeing you. |
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Chiropractic
Examination Forms |
Comprehensive Health Profile
The Comprehensive Health Profile Questionnaire is
used in conjunction with the Comprehensive Wellness
Examination. This 4-page form is useful in setting
up an initial profile of a new practice member and gives
Dr. Michael and Dr. Julie an overview of your concerns
and current health.
As a new practice member, you should download, print
& complete this form prior to coming into the office for
your Comprehensive Wellness Examination with Dr. Michael
or Dr. Julie. Please make sure to bring it with you at
the time of the examination. |
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Quality of Life Questionnaire
This 2-page form presents an overview of your current
quality of life and includes questions regarding your
Physical state, your Emotional state, your current
levels of Stress, as well as an understanding of your
Life Enjoyment and overall Quality of Life.
As a new practice member, you should download, print
& complete this form prior to coming into the office for
your Comprehensive Wellness Examination with Dr. Michael
or Dr. Julie. Please make sure to bring it with you at
the time of the examination. |
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Nutritional
Examination Forms |
Symptoms Survey
The Symptoms Survey is a 3-page survey designed to
help present an overview of your current nutritional
state and how it relates to any symptoms you may be
experiencing. This form will help Dr. Michael or Dr.
Julie to tailor a suggested diet and supplement routine
to help balance your system. |
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Toxicity Questionnaire
The Toxicity Questionnaire is a 2-page survey that is
designed to aid Dr. Michael and Dr. Julie in assessing a
practice member's potential need for a Clinical
Purification Program.This form will help Dr. Michael or
Dr. Julie to tailor a suggested diet and supplement
routine to help balance your system.
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Standard Process Daily Food Intake Journal
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All forms are in Adobe Reader format. If
you do not have Adobe Reader, click the logo below |
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At Gateways to Healing,
Network Chiropractic, our goal is to help you to achieve
better overall health and wellness through chiropractic
care and/or personalized nutritional counseling. We do
not diagnose or treat any particular disease or medical
condition, or offer medical advice. |
