health survey for the ladies
please fill out the form and send it in

Alliance Chiropractic Center
Dr. Fred M. Bogan

1211 S. Harvard - Tulsa, OK
Serving Tulsa Since 1978
we are simply the best
PMS/Menopause
Health Survey

Name Age Phone (Home) ( Work )

Address City

State Zip

Occupation # Hours per week currently working

Spouse Occupation # Hours per week currently working

Your E-Mail Address


Check off any of the following symptoms you have experienced in the past 6 months:

Headaches/Neck Pain
Hot Flashes
Fatigue
Mood Swings
Trouble Sleeping
Irregular Bleeding
Loss of Sex Drive
Back Pain
Anxiety
Night Sweats
Breast Lumps
Joint/Muscle Pain
Water Retention
Heart Palpitations
Sleep Loss
Depression
Tender Breasts
Craving Sweets
Facial Hair Growth
Vaginal Dryness/Infections
Hair Loss
Low Thyroid Activity
Osteoporosis
Dry Skin

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels or affects you when it is at its worst.


Does this cause you to be: Does this affect your work ? Does this affect your Life:

Moody
Irritable
Interrupt Sleep
Restricted on Daily Activities
Stiff/Less Flexible
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours
Lose Patience with Spouse or
Children
Restricted Household Duties
Hinders Ability to Exercise or
Participate in Sports
Interferes with Ability to
Participate in Hobbies or Other Desired Activities

If you checked any of the above items,
then you could be suffering from . . .

EXCESSIVE
STRESS
STRUCTURAL
MISALIGNMENT
PINCHED
NERVES

Alliance Chiropractic Can Help You because Dr. Fred Bogan gently treats the body, naturally,
without drugs to remove the stress and imbalances that CAUSE health problems.

If you could eliminate one of the above which would it be?


There are several alternatives available to you. Please check the item most appropriate for you.

I would like to come to Alliance Chiropractic Center for a complete evaluation.

I would like Dr. Fred Bogan to call me to discuss my health problems before making an appointment.

Are you a member of an HMO or Health Care Network? YES NO

Health Care Provider

 

your information is secure with us

 

 

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