PLEASE COMPLETE THIS ONLINE FORM AND SUBMIT. PLEASE COMPLETE THIS ONLINE FORM AND SUBMIT. PLEASE COMPLETE THIS ONLINE FORM AND SUBMIT. Date * MM DD YYYY Legal Name * First Name Last Name Nickname Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Marital Status Single Married Divorced Widowed Occupation * Employer Have you ever received Chiropractic care? * Yes No Doctor's Name How did you hear about us? * Describe YOUR Healthcare Journey * Neck Pain/Stiffness Low Back Pain/Stiffness Headaches Numbness Arms/Legs/Hands/Feet Sciatica Anxiety Depression Dizziness Tension/Irritability Insomnia Sleep Apnea Fatigue Weight Gain Poor Posture Tinnitus Diarrhea/Constipation Cold Hands/Feet Memory Loss Reproductive Issues Indigestion/Reflux Fainting Sensitivity to Light TMJ Carpal Tunnel Lack of Motivation Hot Flashes What long term benefit are you looking for? Deep/Restful Sleep Healthy Body Weight Little to NO Stress Pain Free Lifestyle Loving Family Relationships Healthy Professional Relationships Focus Motivation Energy Healthy Intamacy Regular Exercise Increased Athletic Activities Financially Secure Balanced Hormones Strong Immune System Clear Skin Healthy Digestion Improved Mental Health Stronger Personal Relationships Improved Cognitive Function Spiritual Growth Improved Time Management Positive Self-Image Improved Confidence Improved Creativity Personal Development Improved Communication Skills Improved Social Life What obstacles do you anticipate encountering along the way? What strategies can you use to overcome these obstacles? How will you celebrate your success once you achieve your health goals? Additional Comments Hello HERO! Thank you for starting your healthcare journey with Kennedy Spine and Sport!
