Primary Condition: __________________________________________________
Submitting Doctor & Practice Location _________________________________
Patient:  male / female, age _____
MD Diagnosis: _________________________________
MD Prognosis: _________________________________
Duration of Condition: ________________
Previous DC care with condition:  yes / no
Outcome:  Resolved / Partially Resolved / ____________________

Brief History: 
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Findings and Care:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Patient Response:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Discussion:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Please Fax this study to me at 425-775-4534.  Thank you for your contribution.

John S. Blye, D.C.    425-775-4533