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Patient Summary Form


PATIENT SUMMARY FORM

Instructions: Please complete this form within the specified timeframe. All PSF submissions should be completed online at: www.mynorthsidehospital/health.com unless otherwise instructed. Please review the Pain Summary for more information.
Personal Information
Gender
Patient Completes This Section
Indicate where you have pain or other symptoms

Please Rate your pain intensity from 0-10. 0 being no pain and 10 being the worst pain. 

4. How often do you experience your symptoms?*
Please select one option
5. How much have your symptoms interfered with your usual daily activities? (including both work outside the home and housework)*
Please select one option
6. How is your condition changing, since care began at this facility?*
Please select one option
7. In general, would you say your overall health right now is...*
Please select one option

This questionnaire will give your provider information about how your neck and back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem. 

NECK

BACK

Thank you for taking the time to fill out this form.

Location

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Office Hours

Our Regular Schedule

Monday:

10:00 am-1:00 pm

4:00 pm-6:30 pm

Tuesday:

4:00 pm-6:00 pm

Wednesday:

10:00 am-1:00 pm

4:00 pm-6:30 pm

Thursday:

4:00 pm-6:00 pm

Friday:

10:00 am-1:00 pm

4:00 pm-6:30 pm

Saturday:

9:00 am-11:00 am

Sunday:

Closed

Testimonials

Reviews By Our Satisfied Patients

  • "My name is Lilian and I have struggled with back pain as a result of poor posture. I have been experiencing scoliosis and nerve aches since my teenage years. After a number of visits with two separate neurologists, their recommendation was to simply use pain medication and accept living in pain. Ultimately, I turned to chiropractic care as a final option. Looking back, I wish I could've known sooner about going to see a chiropractor. This specialized care restored my health and changed my outloo"
    Lilian G.
  • "Excellent service, they explain everything and help you to really improve, not for a simple back adjustment"
    Javier A.
  • "I was diagnosed with fibromyalgia, anxiety disorder and PCOS (polycystic ovary syndrome). I was in constant pain and sometimes wasn't able to do simple household chores. I had horrible fatigue and woke up exhausted every day even if I slept 10 hours. I Had migraines daily and anxiety attacks that eventually would come with no apparent cause. I was depressed and miserable. I went to every specialist: Endocrinologist, cardiologist, neurologist, rheumatologist... Some thought I was crazy and asked "
    A. Mendez
  • "Jennifer had done wonders for my shoulder. My first visit I had shoulder lock and I could barely move my arm at all. Three visits later I have full motion and I haven’t felt better. It’s pretty mind blowing what this place is capable of! Visit ASAP"
    Austin P.
  • "Amazing Doctor. She is very passionate in what she does. Highly recommend her. Her staff is also amazing. I feel great thanks to her skills and compassion. My condition with my back is 95% better thanks to her. Very impressed!!!"
    Pablo R.