Welcome to
Bolt Chiropractic Family Wellness
433 W. Channels Islands Blvd. Port Hueneme, CA 93041
Don Bolt, D.C.
Reason for this Visit
If you are experiencing any pain (neck pain, mid back pain, low back pain, etc.) & or have health problems, symptoms and/or complaints. Please list them in order of severity:
Current Complaints Interfere With Daily Living
The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your health condition
(pain and/or symptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms
you may be experiencing) is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to
each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.
For each of the six categories of daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES.
0 means no disability at all, and a score of 10 means that all of the activities in which you would normally be involved have been totally disrupted or prevented by your health condition (pain and/or symptoms you may be experiencing).
0 1 2 3 4 5 6 7 8 9 10
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Completely Totally
able to function unable to function
If you are experiencing any health problems, please mark the exact location of your pain on the diagram below. Also describe the type and frequency of your pain. For example, dull, sharp, constant, off and on, when standing, sitting, walking, etc.
NOTICE: NOT ALL PATIENTS REQUIRE X-RAYS TO DETERMINE TYPE OF CARE AND LENGTH OF CARE. IF YOUR EXAMINATION WARRANTS X-RAYS ANALYSIS, THE FOLLOWING OFFICE POLICY PREVAILS:
1. All first visit charges are payable when services are rendered.
2. The fee paid for x-rays is for analysis only. We are required to maintain your original x-rays. Films may be loaned to another health provider with your prior authorization only.