Are there any stressful events that have caused an impact on your health and wellbeing?

Present State of Health

What is your body telling you right now? What symptoms are you experiencing? Please explain and describe what is happening in your body.

When did this start?

What do you think the cause is?

What lessens your condition?

What activities aggravate your condition?

Is this condition interfering with:

Work?

Sleep?

Routine?

Other?

What is this stopping you from doing?

If this were to go away tomorrow, what would be different about your life?

Are you ready to make changes to your life in order to heal, even if these changes are inconvenient to your lifestyle?

Please let us know in a few sentences, how we can assist you and help you the most?

What type of results would you like to have with Spinal Flow?

I need relief now and would like the fastest, quickest results.

I would like slower results at a middle pace that fits more into my daily schedule.

I'm interested in improving my spinal flow, but I want the flexibility to pop in when possible.

Consent to Treatment

By e-signing this form, I agree and consent to the healing work.

I understand that with any healing process and work on my body my symptoms may worsen befoe they get better.

I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate fix to my problem, and health is a process.

I have freely decided to undergo the recommended treatment and hare by give my full consent to treatment.

Signature

Date

Present State of Health

Consent to Treatment

RE-EXAMINATION FORM

Previous Care