Move Freely, Live Without Limits

Patient Information

Please list complaints and the date the condition started, starting with your major complaint.

List surgical operations you have had and the approximate date:

Have you ever:

Check the following conditions you have had PRIOR to your current injury, as well as the symptoms you are CURRENTLY experiencing

Pain or numbness in

Muscle and Joint

Eyes, Ears, Nose, and Throat

Endocrine

Respiratory

Skin

Cardiovascular

Gastrointestinal

Genitourinary

Psychological

For Women Only

Date of Last

Habits

I understand that it is my responsibility to keep the appointments that I make. If I am unable for any reason to keep that appointment, I will notify the office of Clay Cox at least 24 hours in advance of that appointment. If I am not able to keep these agreements, I understand that I am responsible for payment for the session missed.