Patient Reactivation 647 346 2281 Watch the video for instructions then fill out the form below. Past Patient Intake Form Intake Form What brings you here * Why did you discontinue care at The Health Loft? * While you were away did you receive chiropractic care by another chiropractor/clinic? * Yes No By who/what clinic? * Any new injuries or accidents since you received care at The Health Loft? * If you are already experiencing a symptom, what is it? * How bad is it? How intense are your symptoms? * 1 2 3 4 5 6 7 8 9 10 1-No Symptoms 10-Intense Symptoms What does it feel like?(check where appropriate) * Aching Burning Cramping Dull Nagging Numbness Sharp Shooting Stiffness Stabbing Swelling Throbbing Tingling If you are human, leave this field blank.