Spinal Decompression Form

Welcome! If you are planning your first visit to Wellness Chiropractic, we look forward to meeting you! To save time on your visit, we encourage you to complete the forms in the convenience of your own home or office. We look forward to seeing you!


Marital Status

I (state your name below) consent to allow Dr. Thalhamer to speak with me and perform an examination (if neccessary) in order to determine if I am a good candidate for non-surgical spinal decompression and also to determine if he is willing to accept my case. It is also my understanding that the consultation is at no charge.

How did you hear about Wellness Chiropractic?

How serious do you think your problem is?

In reference to the severity how would you rate it on a scale of 0-10?

What is your reason for prompting your request for a consultation with the Doctor?

How do you view your problem? (select one)
1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is?
2. What are you hoping happens today as a result of the doctor spending time with you today?
3. Since your back pain became this severe what three things has it caused you to miss the most?
4. How long have you been like this?
5. What chnages/modifications have you had to make and how has your lifestyle change since your back problem?
6. What actions or activities do you have troubles with or are have limitations in?
7. What kinds of treatments have you received?
8. When did you receive these treatments and for how long?
9. Did any of these treatments seem to work in helping your pain? If so which one(s)? For how long?
10. What actions can you take that temporarily decrease the pain?
11. What activities/movements are guaranteed to increase your pain and worsen your condition?
12. What does the pain feel like (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc...) and where?
13. What does it feel like when you wake up compared to the rest of the day? Is it worse in the morning or evening?
14. What do you think will happen to you if you cannot find a solution to your pain/problem?
15. What are you hoping Dr. Thalhamer tells you today?
16. Please express what you hope or imagine his state of the art program and knowledge might be able to accomplish for you?
17. Describe what will be different in your life if you can get better.
18. Please describe in detail the VERY FIRST time you recall having this problem and what it felt like?
List in Order of Importance all OTHER health problems/concerns NOT including your main problem above.
What percentage of time are you aware of your main problem? (select one)
Have you lost any time from work?
How much time and what have you been unable to perform?
Have you lost any time from your obligations at home?
How much time and what tasks have been limited?
Have you lost any time from your family?
How much time and what tasks have been limited?
Have you lost any time from enjoying your lesiure activities? (hobbies, travel, sports, etc...)
How much time and what tasks have been limited?
Considering the amount of pain/discomfort you've had THIS week, how long has your problem been this severe?
On a scale of 0-10 (10 being unbearable, 0 being no pain or discomfort? Please rate the following...
The HIGHEST your pain gets WITHOUT medication.
The LOWEST your pain gets WITHOUT medication.
The HIGHEST your pain gets WITH medication.
The LOWEST your pain gets WITH medication.
List ANY surgeries that you have had and the corresponding dates.

General Health History



Women Only

Date Of Last Period
Date of Last Pap Smear
Have you had a Mammogram?
Are you pregnant?
Number of Children

Men Only




Muscle Joint/Bone








Medications (list any medications you are taking, and dosages)
Allergies to medications or substances
Please type in name below as acknowledgment to sign.
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