70-J Chestnut Ridge Rd • Montvale, NJ 07645
P: (201) 746-0640 • F: (201) 746-6015
www.drjennifermiano.com
My Chiropractic Story
I originally came to see Dr. Jen for:
I had this problem(s) for:
days / weeks / months / years
My problem(s) were affecting my ability to:
( ) work
( ) enjoy hobbies ( ) perform my regular daily activities ( ) care for my family
Other:
Before coming here I tried:
( ) Nothing
( ) Pain Medications
( ) Physical Therapy
Other:
My favorite part of my appointments are:
I have also experienced:
Increased: Energy
Immunity
Range of Motion
Just feel better overall
Other:
Decreased: Stress
Allergy symptoms
Cough/Cold/Sinus problems
Digestive problems
Sleeping problems Cramping/Menstrual Symptoms
Other:
Other Comments:
Name: (Optional):
Do we have your permission to share this information publicly with others who are interested
about chiropractic care with Dr. Jennifer L. Miano? ( ) Yes ( ) No
70-J Chestnut Ridge Rd • Montvale, NJ 07645
P: (201) 746-0640 • F: (201) 746-6015
www.drjennifermiano.com
My Acupuncture Story
I originally came to see Carla for:
I had this problem(s) for:
days / weeks / months / years
My problem(s) were affecting my ability to:
( ) work
( ) enjoy hobbies ( ) perform my regular daily activities ( ) care for my family
Other:
Before coming here I tried:
( ) Nothing
( ) Pain Medications
( ) Physical Therapy
Other:
My favorite part of my appointments are:
I have also experienced:
Increased: Energy
Immunity
Range of Motion
Just feel better overall
Other:
Decreased: Stress
Allergy symptoms
Cough/Cold/Sinus problems
Digestive problems
Sleeping problems Cramping/Menstrual Symptoms
Other:
Other Comments:
Name: (Optional):
Do we have your permission to share this information publicly with others who are interested
about acupuncture at Miano Family Chiropractic Center, LLC? ( ) Yes ( ) No