Instructions

Please fill out as detailed as possible. If anything doesn't apply to you, simply put "N/A" or "None".

Patient Name *

First

Last

Email

(If you don't have en email, simply leave blank)

Cell Phone

Your Date of Birth

Your Age

Some Personal Info We Need

Home Phone

(Simply Enter N/A If You Don't Have a Home Phone)

Work Phone

(Simply Enter N/A If You Don't Have a Work Phone)

SSN#

Winter Address *

Winter Address City *

Winter State and Zip *

Do you have a separate summer address? *

Occupation and Insurance

Tell us about where you work and your current insurance if you have one. Fill in "N/A" on anything that doesn't apply to you.

Employer

Occupation

Insurance

Policy Holder

Policy ID

Policy Holder SSN#

(The social security number of the main policy holder.)

Policy Holder D.O.B.

(The Date of Birth of the main policy holder.)

So... Tell Us About Your Issue.

Chief Complaint

How did it start

Date of onset

(In other words, approximate date the issue started)

Is This Work Related?

Yes
No

Ever had the same or similar symptoms in the past? *

Where are symptoms more dominant?

Left Side
Middle
Right Side

Do you have tingling or numbness anywhere in your body? *

Have you seen another Doctor for this condition? *

Are You Currently Pregnant? *

Yes
No

Do you currently...?

Smoke
Drink
Use Recreational Drugs

Check all that apply, if none do, simply continue.

Almost done... just a few more questions, keep going!

If none of the questions below apply, simply enter "N/A".

List Your Medications

Explain any major falls or accidents

Explain any surgeries or hospitalizations

Date of Last Chiropractic Treatment

(Type "Never" if this is your first visit to a chiropractor.)

Now, simply tick the box below and submit the form.

Medical History Terms & Conditions *

I Agree To The Terms And Conditions Below

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

Basically, we value your right to privacy and we promise never to rent, sell, or give your information to any other third party without your expressed written consent. We adhere to all HIPPA Rules and Regulations and treat your case as confidential at all time.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Instructions

Some Personal Info We Need

Winter Address *

Cool, then just click the button below to continue.

Cool, then simply fill in the address below and then continue...

Summer Address

Occupation and Insurance

So... Tell Us About Your Issue.

Almost done... just a few more questions, keep going!

Now, simply tick the box below and submit the form.

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