Mr. Tyler Johnson DDS

  
 Health survey and History 
 Please describe your injuries: 
 Please Mark the area of your pain on the drawings below 
 Left shoulder Rotator cuff tom 
 x 
 What medications do you take? 
 Acetaminophen 500mg as needed 
 Diclofenac Sod. 50mg as needed 
 How often and how much? 
 as need i tab 
 Did you return to work? ( ) Yes 
 No 
 If yes, how long were you off? 
 Cowecks. 
 Please Make the degree of all conditions which you have, or have had. Using the following letters to rate your condition: 
 Nervous System 
 Cardio-Vascular 
 o = Occasional 
 Eyes, Ear, Nose & Throat 
 F = Frequent 
 Dizziness 
 Chest pain 
 Eye Strain 
 C = Constant 

 Walking problems 
 Patients[Signature) 
 Date: 2014/07/10
 (If minor, parents or guardian's signature) 
 Doctors Signature: 
 Date: 2016/05/12
 Dt: Abraham Chiropractic Playsician 
 Address. 4788 S Florida Ave. Lakeland, FI 33813 Pnone. 863.649.1490 Fax. 863.649.1049
