• New Client Intake Form

  • PERSONAL INFORMATION

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • *We will need to contact you both by phone & email. Please be sure to give us the best phone number to reach you.*

  • Browse Files
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  • Do you plan on using insurance?
  • Retired?*

  • HEALTH HISTORY

  • Please check all that apply*

  • PRESENT HEALTH CONDITION

  • In order of importance, list the health problems you are most interested in getting corrected:

     

  • What makes this pain worse?*
  • Have you seen anyone for this health concern? Chiropractor, Medical Doctor, Etc*
  • Spinal health is especially important during pregnancy; is there ANY chance you are pregnant?*
  • If YES, when is your due date?
     / /
    2 digit month, 2 digit day, 4 digit year

  • LIFESTLYE

  • Exercise?*
  • Work Activity?*
  • Smoking?*
  • Coffee/Caffeine?*
  • Alcohol?*

  • This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.

     

    X-RAY AUTHORIZATION:
    AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THE X-RAYS IN OUR FILES. 

    THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS $15.00, THIS FEE MUST BE PAID IN ADVANCE.


    DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY.


    PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF HUNTER CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE. BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS.

     

     

  • QUALITY OF LIFE

  • Please take several minutes to answer these questions so we can help you get better. (Please be honest with your answers

  • How have you taken care of your health in the past?*
  • How did the previous method(s) work out for you?*
  • How have others been affected by your health condition?*
  • What are you afraid this might be (or beginning) to affect (or will affect)?*
  • Are there any health conditions you are afraid this might turn into?*

  • Wellness Evaluation

  • Please select any conditions that apply to you.

  • Please choose the number that most closely fits to you.

    0 = Does not Apply to Me, 3 = Very Prominent Issue
  • Constipation and/or Diarrhea
  • Abdominal Pain or Bloating
  • Mucous or Blood in Stool
  • Joint Pain or Swelling, Arthritis
  • Chronic or Frequent Fatigue or Tiredness
  • Food Allergies, Sensitivities, or Intolerances
  • Sinus or Nasal Congestion
  • Chronic or Frequent Inflammations
  • Eczema, Skin Rashes, Hives (Urticaria)
  • Asthma, Hay Fever, or Airborne Allergies
  • Confusion, Poor Memory, Mood Swings
  • Use of NSAIDS (Aspirin, Tylenol, Motrin)
  • History of Antibiotic Use
  • Alcohol consumption makes you feel sick or ill
  • Ulcerative Colitis or Celiac's Disease
  • Nausea
  • Weight Trouble
  • Should be Empty: