Assessment Name PLEASE READ -- The consultation is a way for you and the doctor to meet one-on-one to discuss any questions, comments, and concerns that you may have. You get the chance to see some of the chiropractic neurological exams, tests, modalities, and adjustments that are implemented in the office. Please provide as much information that you can in the form below. 1. Client Information First Name: * Last Name: * E-mail: * Date: * Occupation: Date of Birth: * Sex: * Male Female Other 2. Getting to Know You Describe your condition: When did this begin? Check all that apply: Neck/back pain Balance issues Migraines Previous Concussion(s) Brain-fog Anxiety Panic Attacks Does your condition affect the following issue(s)? Does it wake you up at night? Yes No Trouble concentrating? Yes No Affect your daily life (working, playing with kids, exercising, etc.)? Yes No Does it cause pain? Yes No 3. Balance Issues (leave blank if not apply) Do you experience a sense of being off-balance (disequilibrium)? Yes No Has/does your condition make you fall? Yes No How long has this been going on? 6 Months 1 Year 3+ Years Is your falling from being off balance or weakness in legs? Weakness Off-Balance Are you on any medications? Yes No Have you seen a chiropractor/MD for this condition before? Yes No 4. Neck/Back Pain (leave blank if not apply) Where is your pain? When does it start? What makes it better? What makes it worse? What type of pain? Sharp Stabbing Burning Achy Tender Does the pain travel anywhere? Yes No Have you seen a Chiropractor for this condition before? Yes No 5. Other Neurological/Musculoskeletal Conditions If there is any other information you would like to provide please use the additional lines provided- such as migraines, anxiety, brain-fog, etc. Thank You for filling out the information and submitting it to the website. The above information allows Dr. Walker to have a better understanding of what is going on with you and get to know you better.