I understand and agree that health and accident insurance policis are an agreement between the insurance carries and myself. Futhermore, I understand that the chiropractic clinic will prepare any necessary reports and forms to assist me in making collection form the insurance company and that any amount authorized is to be paid directly to the chiropractic clinic and will be credited to my account upon receipt. However, I clearly understand that if I suspend or terminatie my care or treatment, any fees for professional services rendered me will be immeduatley due and payable. I agree that I am responsible for all bills incurred at this office. I hearby authorize the doctor to treat my condition as he or she deems appropriate through the use of Chiropractic Health care, and I give authority for these procedures to be preformed. I futher understand that all procedure preformed by the doctor is in relation to a neuromusculoskeletal complaint and falls within the scope of practice set forth by the state chiropractic board.

In order to properly assess your condition we must understand how much neck and/or back problems have affected your ability to manage everyday activities. For each item below please circle the number which most closely describes your condition right now.