Kristina Brown's Clinic
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Medical Info
Primary Complaint
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General Health
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Insurance Info
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Claims / Benefit
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Health Advice for Healing
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Support in Healing/Recovery
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Other
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TMJ (Jaw)
Ear Stuffiness
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Grinding
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Clenching
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Clicking
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Jaw Pain
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Difficulty Chewing
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Locking
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Difficulty Opening Jaw
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Morning Stiffness
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Ear Blockage
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Ear Pressure
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Ear Ringing
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Energy
Is your energy constant?
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What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Well Being
Caffeine
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Smoking
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Drinking
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Sports
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Exercise
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Flexibility
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Hobbies
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Interests
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Mobility/Walking Aids
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Range of Motion
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Health Questions
Depression
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Past Heart Surgery
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Epilepsy
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Schizophrenia
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Hearing Impairment
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Stroke
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Vertigo
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Heart Attack
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Heart Condition
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Asthma
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Meniere Disease
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Concussion
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Mood Disorder
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Congenital Heart Defect
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Pacemaker
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Energy Level
Even
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Fatigue
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Flat
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High
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Agitated
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Low
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Chaotic
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Vibrant
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Clear
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Dull
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Infectious
Epstein Barr
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Lyme Disease
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Pneumonia
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Strep
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Female Health
PMS
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Severe Menstrual Pain
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Number of Pregnancies
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Osteoporosis
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Currently Pregnant
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Cluster
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Rebound
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Sinus
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Chronic Daily Headache
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Tension
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Migraines
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Headaches
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Other Headaches
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Musculoskeletal
Fracture
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Joint Stiffness / Swelling
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Artificial Joints / Special Equipment
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Hereditary/Congenital Deformity
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Plantar Fasciitis
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Jaw Pain (TMJD)
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Joint Injury
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Spasms / Cramps
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Psoriatic Arthritis
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Broken Bone / Fracture
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Torticollis
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Osteoarthritis
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Scoliosis
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Carpal Tunnel Syndrome
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Tendonitis/Bursitis
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Whiplash
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Fibromyalgia
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Strain/Sprain
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Chronic Fatigue Syndrome
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Arthritis
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Ankylosing Spondylitis
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Amyotrophic Lateral Sclerosis (ALS)
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Chronic Myofascial Pain Syndrome
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Bone Disease
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Dislocation
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Degenerative Disk Disease
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Osteoporosis
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Endocrine
Hyperthyroidism
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Hypothyroidism
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Diabetes
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Family History
Cardiovascular
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Respiratory
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Arthritis
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Gastrointestinal
Stomach Disorder
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Ulcerative Colitis
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Celiac Disease
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Crohn's Disease
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Constipation
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Diarrhea
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Eating Disorder
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Digestive Conditions
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Irritable Bowel Syndrome
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Poor Appetite
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Cardiovascular
Fainting Spells
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High Blood Pressure
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Coronary Artery Disease
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Stroke
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Low Blood Pressure
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Congestive Heart Failure
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Blood Clots
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Cardiovascular Conditions
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Heart Attack
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Cardiovascular Accident
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Cold Hands
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Pacemaker
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Cold Feet
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Chest Pain
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Aneurysm
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Insomnia
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ADHD
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Loss of Balance
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Weeks Pregnant
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Abdominal Cramping
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Edema/Swelling
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Leg Cramps
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Nausea
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Sciatica
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Twins or More
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Heart Attack
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Stroke
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Carpal Tunnel Syndrome
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High Risk Pregnancy
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Sacral Injury
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Tailbone Injury
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Emotion / Mood
Physical Abuse History
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Depression
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PTSD
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Despair
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Rate the stress in your life (1-10)
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Fear
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Sadness
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Grief
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Stress Response and Coping Strategies
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Mental Abuse History
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Anger
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Negative Self-Talk
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Other Emotions
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Anxiety
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Overall mood and energy level
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Confusion
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