Wellness Evaluation Form

1930 S Bascom Ave Suite 230, Campbell, CA 95008 

(408) 340-5055  |  LifeGiving-Chiro.com  |  [email protected]

Personal Information

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I acknowledge Life Giving Chiropractic's Notice of Privacy Practices and I also understand that my personal health information is protected by HIPAA and may only be disclosed for treatment, payment, or healthcare operations.


Wellness Evaluation

Note: In medicine today, leaky gut aka intestinal permeability isn't typically diagnosed. However, that doesn't mean it's not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this evaluation to help our doctors determine how we can help your condition.

                                                                                                                  

Let's get started

Please check any that apply to you

Sub-Clinical Symptoms Including:

Autoimmune Conditions Including:

Headaches
Diabetes Mellitus
Migraines
Lupus

Hormone Imbalance Including:

Rheumatoid Arthritis
Premenstrual Syndrome
Fibromyalgia
Emotional Imbalance
Chronic Fatigue

Gastrointestinal Issues Including:

Thyroid Conditions Including:

Abdominal Bloating, Cramps or Painful Gas
Hashimotos
Irritable Bowel Syndrome
Hyperthyroidism
Ulcerative Colitis
Hypothyroidism
Crohn's Disease

Developmental and Social Concerns Including:

Condiciones Respiratorias, Incluyendo:

Autism
Chronic Sinusitis
ADD/ADHD
Asthma

Skin Conditions Including:

Allergies
Eczema

Joint Conditions Including:

Skin Rashes
Knee, Shoulder or Spine
Hives



Check the number that most closely fits, then add up your results: 

[0 = None 1 = Mild 2 = Moderate 3 = Severe]

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

Location

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Office Hours

Chiropractic

Monday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

Massage Therapy

Monday

Closed

Tuesday

Closed

Wednesday

Closed

Thursday

10:00 am - 5:00 pm

Friday

10:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Chiropractic

Monday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
Closed
Wednesday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Thursday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Saturday
Closed
Sunday
Closed

Massage Therapy

Monday
Closed
Tuesday
Closed
Wednesday
Closed
Thursday
10:00 am - 5:00 pm
Friday
10:00 am - 5:00 pm
Saturday
Closed
Sunday
Closed