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PATIENT INFORMATION

Please fill out the following form and then select SUBMIT at the bottom.


Name * :
Age * :
Birthdate * :
Address * :
City * :
State * :
Zip * :
Home Phone :
Work Phone :
Cell :
Email * :
Maritial Status--select one: :
Employer * :
Occupation :
Whom to contact in case of emergency: * :
Whom may we thank for referring you to our office? * :
Do you have a Primary Care Physician? :
Name and Location of Primary Care Physician: :
Do you have an Internal Medicine Physician? :
Name and location of Internal Medicine Physician :
Has a physician treated you for any health condition in the last year? :
If yes please explain: :
List the approximate dates of any operations and/or serious illnesses or accidents you have had (Include broken bones): :
List all drugs or medication that you are on now or have or have used recently (i.e. aspirin-sleeping pills-birth control-etc...): * :
Have you received Chiropractic treatment previously? :
Name and location of previous chiropractor: :
INFORMATION OF CONDITION :
Please describe the principal health problems for which you came to this office: :
How and when did the symptoms first occur? :
List any doctors or clinics seen for the problems: :
List diagnosis(es) and type of treatment (s): :
Does this interfere with your normal living and working? :
In what way? :
Have you lost any dates of work? :
Dates: :
Have you had similar injuries or symptoms before? :
If yes please explain: :
Have any of your relatives had similar conditions? :
If yes please list relations: :
List the conditions that you are most interested in getting corrected. Rank by importance: :
1. :
2. :
3. :
4. :
What functions are you unable to perform or induce pain upon performance? List in order of severity. (Examples: sitting-walking-bending-lying down-etc...) :
1. :
2. :
3. :
4. :
I have made every effort to provide accurate and reliable information while answering the questions asked above. * :
Please copy the 5 characters :

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