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1. What is your name?

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2. List your degrees, credentials etc?

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3. What is the city, state, region/province and country where you practice?

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4. What is the sex of the patient?

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5. How old was the patient when they started care?

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6. If the patient experienced an improvement in some disease, disorder or syndrome please list or state what it was here. You can list more than one - there is no limit. If there is more than one and there is one that is most significant or dramatic please note that. If this is purely about objective reduction of vertebral subluxation and there was no other disease, disorder or syndrome please state that.

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7. Describe what the presenting complaints were for this patient

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8. Describe or list any previous treatment the patient had.

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9. Describe/list any testing the patient had such as MRI’s, laboratory work etc and what the results were if known.

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10. List any medical diagnoses the patient was given (If known)

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11. Do you have copies of any of the patients medical records? Yes or No.

If Yes - please list what you have.

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12. Briefly describe what you did to or for the patient. Include chiropractic, nutritional, exercise, physiotherapy, lifestyle modifications and any other things that the patient did differently after getting under your care. Be as thorough as possible.

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13. What chiropractic technique(s) did you use?

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14. What were the most significant chiropractic findings from your initial and follow-up exams? Include subluxation findings, listings, palpation, posture etc. This is extremely important so please be thorough.

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15. Did you take x-rays?

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16. If you took x-rays please list what views you took.

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17. If you took x-rays - List any pathological and/or chiropractic biomechanical findings on the x-rays including measurements such as cervical curve, atlas/axis angle, subluxation listings etc.

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18. Did you take post x-rays? If so, what improved on the post x-rays?

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19. Did you use thermography? If yes, how many scans did you do and what were the thermographic findings?

Include pre and post changes.

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20. Did you use surface EMG? If yes, how many scnas did you do and what were the SEMG findings?

Include pre and post findings.

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21. Did you use ROM? If yes, what were the results?

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22. Did you use any other type of objective testing using machines, computerized diagnostics etc? List and tell us the results.

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23. How many visits did you see the patient for?

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24. What was the frequency of care - i.e. how many times per week, per month etc?

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25. How long did you see them for in terms of days, weeks, months, years?

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26. How many visits before they started to improve?

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27. What were the improvements they experienced from care? Include subjective improvements and what the patient reported and also include any and all objective improvements. Include things like chiropractic findings, palpation, ROM, instrumentation, x-ray etc.

This question is crucial so be thorough.

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28. Is the patient still under care?

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29. If they are still under care what is the frequency of care now?

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30. List or describe anything else significant about this case that has not already been described. Or tell us anything else you want to tell us about this case or your experience with it.

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31. List or describe anything the patient said or experienced that has not already been described.

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