A.I.M.S. Clinic

Name:

Age:

Address:

City:

State:

Zip:

Email:

Phone (home):

Phone (work):

Ext:

Fax:

Best Time to Call:

Check the Symptoms or Conditions You've Experiences In The Last 6 Months
Pain Anywhere	Weight Concern	Back Pain
Asthma / Allergies	Numbness/Tingling	Knee Pain
Digestive Disorders	Shoulder Pain	Hip Pain
Headaches	ADD / ADHD	Stress Tension
Dizziness	Neck Pain	Fibromyalgia
Difficulty Sleeping	Hand / Wrist Pain	High Cholesterol
High Blood Pressure	Fatigue	Irritability

Please Provide Additional Comments

THE FOLLOWING FORMS NEED TO BE FILLED AND BROUGHT IN ON YOUR INITIAL VISIT