Hands 2 Health Wellness Center

Dr. Theresa L. Smith
80 Montecito Court
Sierra Madre, CA 91024
(626) 355-2626

Patient Forms

CHIROPRACTIC FORMS:

• Confidential Patient Information
• Chiropractic Health Questionnaire
• Pain Map Chart

FUNCTIONAL DIAGNOSTIC MEDICINE FORMS:

• FDM Health Questionnaire
• Nutritional Assessment Questionnaire

NUTRITION EVALUATION FORMS:

• Nutritional Assessment Questionnaire
• Diet Diary
• Detoxification Questionnaire

MISCELLANEOUS FORMS:

• Consent to Treat Child (Minor)