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Most patients have had dozens of IMPACTS throughout their life that could cause SUBLUXATIONS (spinal misalignments). The doctor wants to discover at least 5 of yours. List below any auto accidents, work, home, sports injuries, or falls.


Quality of Life Ratings 

Subluxations affect our quality of life in many ways. Please enter the number between 0-10 (0 = none, 10 = worst imaginable) that best represents how you rate your quality of life and lifestyle habits.