Location (Where does it hurt?)
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Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)
How does your current condition interfere with your:
Surgical interventions, which may or may not have included hospitalization.
Other interventions, which may or may not have included hospitalization.
Medications and Supplements
(Please list all prescriptions over-the-counter, natural supplements, enzymes, vitamins and minerals)
In order to improve your health, how willing are you to:
Thank you for taking the time to complete this health history medical questionnaire. The information derived from all of this information will provide invaluable data in identifying the underlying problems of your health concerns rather than simply treating the symptoms alone.
We look forward to helping you achieve lifelong health and wellbeing.
Yours in Health,
Dr. Mark LeMay & Team
Our Mission is to assist you in strengthening and supporting your body. To help you go from symptoms controlling your life, to easily adapting to life's challenges.
We strive to provide our patients with the utmost professional and excellence of service. Our commitment to your well-being and enhancement of your health is taken very seriously by the doctor and members of this office.
Because we care so much about you we realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need to receive and to the actions we ask you to do.
Your adherence to the number of treatments is a vital component of your progress with our services; therefore, we have certain rules that need to be followed in order to ensure the most optimal results.
In an instance of repeated non-compliance with your scheduled visits, we also reserve the right to discontinue care. If this were to happen, we will gladly refer you to another chiropractic office.
We appreciate you greatly as our patient and strive to accomplish the best result that we can for your health and well-being.
I understand and agree to adhere to the missed appointment and cancellation policy.
Office Staff | Date (MM/DD/YYYY)
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LeMay Chiropractic & Wellness8080 Madison Ave, Ste 204AFair Oaks, CA 95628Phone: (916) 965-8171