• WELCOME

  • Confidential Health History

    • Winston-Salem
    • 3570 Vest Mill Road, #B • Winston-Salem, NC 27103

  • Cary Hall, DC

  • ABOUT YOU

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    Do you reside with a relative?

  • IN EVENT OF EMERGENCY

  • HOSPITAL / EMERGENCY ROOM

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  • If you have a report - please give to our staff - so copy can be made)

  • Did ER doctor write you out of work?

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  • Did ER doctor write you a work restriction? 

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  • 4 Is Liringis Chiropractic the only doctor’s office you have been to for this accident? If no, fill in the following:

  • OTHER MEDICAL PROVIDERS OTHER THAN HOSPITAL/EMERGENCY ROOM

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  • Currently treating? Yes or No

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  • HEALTH HISTORY

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  • 7.For women: Are you taking birth control? o Yes o No Are you nursing? o Yes o No

  • We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

    HIPAA Compliance - Our office is required by law to maintain the HIPAA Notice of Privacy Practices. This notice explains our legal duties and privacy practices with respect to your protected health insurance. Signature below acknowledges that I have read this Notice of our Privacy Practices. A copy will be provided to me upon request.

    I authorize the staff to perform any necessary medical services needed during diagnosis and treatment.

    I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

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