Please fill out your Health Record as completely and accurately as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.

It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being through natural Chiropractic care.

Confidential Patient Information

Gender Assigned at Birth

Male

Female

Your Marital Status

Single

Divorced

Married

In a domestic partnership

Children (Names and Ages)

Employer Information

Reason For This Visit

When did this condition begin?

Is the purpose of this appointment related to:

If job related, have you made a report of your accident to your employer?

Yes

Overall Frequency of Complaint (choose one)

Constant - 100% of the time

Frequent - 75%

Intermittent - 50%

Occasional - 25%

Overall Intensity of Complaint (choose one)

Minimal (An annoyance but has no effect on activity)

Slight (Tolerable with some impairment to activity)

Moderate (Tolerable with marked impairment of activity)

Severe (Intolerable and cannot perform any activities)

What makes the discomfort better? (Check all that apply.)

Has This Condition:

Gotten Worse

Stayed Constant

Comes and Goes

Gotten Better

On a scale of 0 to 10, 0 being no pain, 10 being the worst pain you have ever had, where would you rate your current level of pain?

What makes the discomfort worse? (Check all that apply.)

MARK THE BOXES BELOW, WHERE YOU FEEL PAIN, NUMBNESS OR TINGLING:

Mark whichever number(s) correlates to the area(s) of complaints on the graphic above

Has this condition happened before?

Does this condition interfere with:

Work

Sleep

Daily Routine

Other Activities

Have you seen other doctors for this condition?

Yes

EXPERIENCE WITH CHIROPRACTIC

Whom may we thank for referring you to us?

Have you been adjusted by a chiropractor before?

Approx Date of Last Visit

Reason for those visits?

Has this condition happened before? If so, please explain.

GOALS FOR MY CARE

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Comprehensive Care: Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

Yes

Corrective Care: Correcting and relieving the cause of the problem as well as the symptoms

Yes

Relief Care: Symptomatic relief of pain or discomfort

Yes

HEALTH CONDITIONS

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Musculoskeletal Conditions (Please check all that apply.)

Neurological Conditions (Please check all that apply.)

Heat/ENT Conditions (Please check all that apply.)

Cardiovascular Conditions (Please check all that apply.)

Genitourinary Conditions (Please check all that apply.)

Respiratory Conditions (Please check all that apply.)

Gastrointestinal Conditions (Please check all that apply.)

Endocrine Conditions (Please check all that apply.)

Allergies (Please check all that apply.)

Dermatologic or Hemopoietic Conditions (Please check all that apply.)

Past Surgeries (Please check all that apply.)

Things I do currently to support my health include:

Do you smoke?

Yes

Do you drink coffee?

Yes

Do you drink alcohol?

Yes

Do you exercise regularly?

Daily

Moderately

Do you wear:

Heel Lifts

Soul Lifts

Inner Soles

Arch Supports

List any Rx and Non-Rx Medications Taken Regularly

List any Supplements & Vitamins Taken Regularly

Are you pregnant?

Yes

Are you nursing?

Yes

Are you taking birth control?

Yes

Do you experience painful periods?

Yes

Do you have irregular cycles?

Yes

Do you have breast implants?

Yes

EMERGENCY CONTACT

Emergency Contact Name

Emergency Contact Home Phone Number

BILLING/INSURANCE

Please bring your insurance card with you to your appointment for verification of benefits. We will verify all benefits per your agreement with your carrier. After verification the Doctor will give his/her recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.

I understand that my insurance policy is an arrangement between myself and my insurance carrier and that all services rendered, that are not covered under my insurance plan, are my responsibility. My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit

I have read and agree to the above statements.

Guardian or Spouse's Signature

Clear

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.