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Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

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Car Accident? Pain?

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Health Insurance or Self Pay Forms

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    MaleFemale













    SingleMarriedDivorcedWidowed


    WhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answer

    StandingSleepingTwistingSittingBendingLiftingWalkingSneezingCoughingLying DownSexual ActivityOther

    ImprovingGetting WorseAbout the sameIntermittent (come & go)


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    Auto AccidentWork RelatedFall






    EatingBathingToiletingTransferringDressingGroomingSleepingThinkingSittingWalkingStairsReachingLiftingBendingStoopingKneelingSquattingGraspingWeakness





    AsthmaBowel disorderCancerDepressionDiabetesBladder disorderHeart diseaseKidney diseaseLung diseaseBronchitisTuberculosisStrokePolioHigh Blood pressureRheumatismSeizureMental IllnessThyroidUlcer



    DiabetesRheumatoid arthritisBack problemsCancerTuberculosisHeart AttacksHypertension





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    double visionblurred visionringing in the earsdizzypoor hearingsevere headachesevere recurrent nose bleeddifficulty swallowing

    dull chest painpressure/tightnesschest palpitations (fluttering)shortness of breath at restshortness of breath with exertionshortness of breath when lying flatcoughingcoughing up bloodswelling feetsevere sweating at night

    abdominal painvomitingvomiting bloodblack & tarry stoolbloody stoolsclay colored stoolsloss of bowel controldramatic change in bowel habitsjaundice (yellowing of skin, eyes)

    burning on urinationblood in urineunitary frequencyloss of bladder controlpenile or vaginal dischargepenile or vaginal bleedinggenital sores

    joint painjoint swellinggrinding of jointslocking of jointsneck painback pain

    feverchillsnight sweatsloss of appetiteunintentional weight loss

    Paralysis in arms or legsnumbness in arms or legsloss of consciousnessseizurestremorsjerkingpoor coordination

    loss of hairdry soresitchinessrashes

    increase thirstexcessive urinationexcessive drinkinghot/cold intoleranceexcessive sweating

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    Find Us!

    Hours of Operation

    Our Office Hours Are As Follows:

    • Monday 7:30 to 6:00
    • Tuesday 7:30 to 6:00
    • Wednesday 7:30 to noon
    • Thursday 7:30 to 6:00
    • Friday 7:30 to 6:00

    Contact Us

    Phone: (352) 351-3413
    Fax: (352) 629-6667
    Address:1009 SW 16th Lane

    Ocala, FL 34471

    Copyright 2015 ·

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    • About
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    • Ocala Car Accident Doctor
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    • Ocala Chiropractor V1
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