Impairment Paperwork


Impairment – Loss of Enjoyment Sports/Hobbies/Travel/Daily Activities & School

New Port Richey


Please fill out the following questions as completely and accurate as possible to give our staff as much information as possible about you and your condition. You may text or call us with any questions you may have. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with chiropractic care

Please check all the DAILY LIVING Activities that cause you pain because of the accident:*
Please select at least one option
Please check all that apply to your EXERCISE & SPORTS Activities because of the accident:
Have you gained any weight since the accident? if so, how many pounds?
Have you had to quit any sport teams? If so, what sports?
Have you lost interest in playing any sports? If so, which one?
Have you lost interest in playing any sports for a limited time? If so, which one and for how long?

Please list all your HOBBY activities and how they were affected because of the accident:

Please answer the following question about hobby #1.
Please answer the following question about hobby #2.
Please answer the following question about hobby #3.
Please check all that apply to your TRAVEL Activities because of the accident:
Travel Plan #1
Travel Plan #2
Please check all that apply to your SCHOOL & EDUCATION Activities because of the accident:

Thank you for taking the time to fill out this form.