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value. quality care. convenience.

CAR ACCIDENT & WORK INJURIES

Chirorpractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Your Chiropractic
Center

Chirporactor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

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Subjective, Objective, Assessment and Plan (SOAP) Notes

Patient First Name

Patient Last Name

Phone Number

First Visit? *

Yes

No

WHAT HURTS
(Recent injury or since previous visit)

Head & Neck.png

Head & Neck

Headache

Neck Pain

Vision Problems

Ringing in Ears

Dizziness

Anxiety

Depression

Chest & Stomach

Chest Pain

Indigestion

Upset Stomach

Loss of Appetite

Diarrhea

Constipation

Back & Shoulders

Upper Back Pain

Lower Back Pain

Middle Back Pain

Shoulder Pain

Hip Pain

Arms & Hands.png

Arms & Hands

Arm Pain

Elbow Pain

Wrist Pain

Hand Pain

Arm Numbness or Tingling

Hand Numbness or Tingling

Arm Burning

Legs & Feet

Leg Pain

Knee Pain

Ankle Pain

Foot Pain

Leg Numbness or Tingling

Leg Burning

Hip Pain

LEVEL OF PAIN

Due to my injuries I find it difficult to:

Work

Bend

Lift

Sleep

Concentrate

Drive

Sit

Stand

Do Housework

Patient Signature

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

info americanbackcare.net

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Chiropractor Charlotte Concord Gastonia Lancaster Monroe Rock Hill

Monday - Friday 7:00am - 8:00pm
Saturday 8:00am - 1:00pm
Sunday Closed

© 2023 American Back Care Chiropractic

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