PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

Digestive Track
__nausea & vomiting Heart
__diarrhea __Irregular/Skipped Heartbeat S Nose
__constipation __Rapid/Pounding Heartbeat S __stuffy nose
__bloated feeling __Chest Pain S __chronically red/inflamed nose
__stomach pains or cramps __sinus problems
__heart burn __hay fever
__blood and/or mucous in stools __sneezing attacks
Joints & Muscles __excessive mucous formation
__pains/aches in joints
Ears __arthritis/osteoarthritis Skin
__itchy ears __stiffness/limited movement __acne
__ear aches/ear infections __pain/aches in muscles __itching
__drainage from ear __feeling weak/tired __hives/rash/dry skin
__ringing in ears __swollen/tender joints __hair loss
__hearing loss __growing pains in legs __flushing/hot flashes
__reddening of ears __Psoriatic/Gouty Arthritis S
__Rheumatoid Arthritis S Weight
__binge eating/drinking
Emotions Lungs __craving certain foods
__mood swings __chest congestion __excessive weight
__anxiety/fear/nervousness __bronchitis __compulsive eating
__anger/irritability/aggressiveness __shortness of breath __water retention
__argumentative __difficulty breathing
__frustrated/cries easily __persistent cough General
__Depression S __wheezing __frequent illness
__frequent/urgent urination
__genital itch/discharge
__anal itching
Eyes Mind
__watery or itchy eyes __poor memory Genitourinary
__red/swollen/itchy eyelids __difficulty completing projects __kidney problems
__bags or dark circles under eyes __difficulty with mathematics __urinary tract
__blurred or tunnel vision __underachiever __bladder
__poor/short attention span __yeast infections
__confusion
__easily distracted Other Conditions
Head __difficulty making decisions __Autism S
__headaches __mild learning Disabilities __A.D.H.D. S
__faintness __A.D.D. S
__dizziness Mouth & Throat Thrush __Psoriasis S
__insomnia/sleep disorder __chronic coughing __Eczema S
__facial flushing __gagging/clearing throat often __Auto Immune Disorder S
__sore throat/hoarse voice/voice loss __Chronic Fatigue S
__swollen/discolored tongue/lips __Multiple Chemical Sensitivities S
__canker sores __Asthma S
__itching on roof of mouth __Congestive Heart Failure S
__Severe Diabetic S
__Severe Depression S
Date__________________________ __Obsessive Compulsive Disorder S

Patient
Name__________________________
Access Wellness at Hirsch – Starr Chiropractic
2850 Johnson Ferry Road, Suite 150, Marietta, GA 30062
(877) 579-5815