The symptom(s) that have prompted you to seek care:
Please check off the areas where you are experiencing your symptoms
How does your current condition affect your daily activities? Please respond only for activites that it affects.
Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. How is your body functioning? Have you had any of the following?
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Sensory
Endocrine
Genitourinary
Constitutional
Illnesses
Surgeries
Medications
Family History
Social History
I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.
I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.
I realize that an X-ray examination may be hazardous to an unborn child and certify that to the best of my knowledge I am not pregnant.
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.