Therapy-Questionnaire

Please take your time to carefully fill out the medical history form. It is a very important basis for your first treatment in our practice. If you do not wish to provide certain personal information in writing, you are free to do so. Your information will of course be treated confidentially and is subject to medical confidentiality.
Thank you very much, IHR-CHIROPRAKTOR Team
(Fields marked with * are required)

Your current complaints

Körper

right

left

right

(0=No complaints, 10=Extreme complaints)
Complaints: 0
(0=No complaints, 10=Extreme complaints)
Complaints: 0

Your health background

Your daily habits

Conclusion



Data Protection * (more information)

Riskinformation / Risk disclosure * (more information)

Knowledge and conscience Headline *