_____Yes ____No If yes, how many cigarettes per day? _____
Do you have any allergies?
____ Yes ____ No If yes, please list any known allergies: ________________________________________________________________________________________________________________________________________________________
Job Title and Description: ______________________________________________________________________
What do you do most of the day at work?
____ Sit ___Stand ___Light Labor ___Heavy Labor ___ Other
How often do you consume alcohol or use recreational drugs? _________
What kind? _________________________________________________
Cleveland Chiropractic & Wellness Center
Dr. Emily Arnold-Wheat
2460 Fairmount Blvd.
The Heights Medical Building, Unit B
Cleveland Hts., OH 44106 Health Review
How many hours of sleep are you getting per night? Is your sleep routine?
___Less than 5 ___6-8 ___8-10 ___10 or more
Do you have trouble falling to sleep? Staying asleep?
How would you rate your sleep on the following scale?
No/Poor Sleep1 2 3 4 5 6 7 8 9 10 Fully Rested How many days a week do you exercise for 30 minutes or more? ____ Days
How would you rate your stress level?
Low 1 2 3 4 5 6 7 8 9 10 High List your major stressors: _____________________________________________________________________________
What are your expectations for care at Cleveland Chiropractic and Wellness Center? _____________________________________________________________________________
Your nutritional-wellness care plan in this office is not designed to replace, negate or cancel out the medical care plan prescribed by your primary care physician. Instead, it is designed as an alternative health care adjunct to incorporate food, supplements, vitamins, lifestyle changes, and herbal regimens to assist you in achieving your health and wellness goals. Nutritional counseling, vitamin recommendations, nutritional advice and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. Your health is ultimately your responsibility and therefore our treatment regimens are highly suggested plans yielding highly favorable outcomes, depending upon your full compliance and adherence. The wellness plans are uniquely designed for your individual case. Our method of wellness care is supported by the results of clinical and cutting edge scientific research. Therefore, the products recommended in your health and wellness plan have not been regulated by the FDA as they are not classified as drugs.