This document appears to be a patient intake form asking for information including the patient's name, condition that brought them to the chiropractor's office, length of experiencing problems, prior treatments tried, how they were referred to the chiropractor, results of care, unexpected positive changes experienced, if they would recommend NUCCA care to others, and if they have anything else to add.

1. Name:
What condition brought you into the office and how
long had you been experiencingproblems?
Did you try anything before chiropractic?
How were you referredto Doyle Chiropractic?
What have your results been?
Did you experience any positive changes that you
did not expect?
Would you recommend NUCCA care to anyone else?
Is there anything else you would like to add?