South Bay, Hermosa Beach Chiropractor, Dr. Matthew Costantino, D.C.

1. What is your main area of complaint? Headache, Neck, Upper Back, Middle Back, Lower Back, Hips, Shoulders, Arms, Legs, Other

2. How often does this complaint bother you? Please Select One Constant Daily 3x Week 1x Week 2x Month 1x Month

3. Do you know what may have caused this complaint? Please Select One Auto Work Sports Injury Fall Other

4. When it is at its worst, describe how it feels:

5. A. Has it been bothering you for more than a couple of days? Please Select One Yes No

5. B. If "Yes", how long?

6. Does it prevent you from participating in any activities you enjoy? Please Select One Yes No

6. B. If "Yes", which activities?

7. Have you tried any treatment for this problem, such as ice, heat, rest, motrin, muscle relaxers, physical therapy, or anything else which has not resolved this complaint as of yet? change to: Have you tried any self treatment for this problem, such as ice, heat, rest, pain medications, muscle relaxers, exercises, or anything else which has not resolved this complaint as of yet?

8. Have you been treated by any doctors or therapists for this condition?

9. What were the results of this treatment?

10. What is most important to you? Please Select One Initial Relief of Symptoms Correction of Problem Maintaining Wellness

Any additional information that might be important for my evaluation of your complaint or any specific questions for Dr. Costantino: