Health History

  • New Patient Health History

  • Today's Date*
     - -
  • Patient Birth Date*
     - -

  • Contact Info

  • Format: (000) 000-0000.
  • Marital Status
  • Work Status

  • Experience

  • Have you ever been to a chiropractor before?*
  • Did you have good results?

  • Personal Injury

  • Are you coming in because you were in a motor vehicle accident?*
  • Date of the accident*
     - -
  • Did you lose consciousness?
  • Did you go to the hospital?*

  • Your Vehicle Insurance Info

    MedPay is an optional addition to the regular coverage on your policy. It covers your medical expenses and does not affect your deducible nor raise your premium.
  • Do you have MedPay (Medical Payments) on your policy?*
  • Was anyone ticketed?*

  • 3rd Party's Insurance Info

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  • Health History - Click or tap "Next" to begin

  • Do you have health insurance?*
  • Insurance Carrier*
  • Subscriber Birth Date*
     - -
  • Format: (000) 000-0000.

  • What can we help you with?

    Details on your current condition(s). This online form allows you to submit up to 4 conditions. Please focus on one at a time.
  • Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*
  • Location of issue*
  • How does it feel?*
  • Whom else have you seen for this episode?*
  • "I am concerned because it..."
  • Is anything else bothering you?*
  • Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*
  • Location of issue*
  • How does it feel?*
  • Whom else have you seen for this episode?*
  • "I am concerned because it..."
  • Is anything else bothering you?*
  • Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*
  • Location of issue*
  • How does it feel?*
  • Whom else have you seen for this episode?*
  • "I am concerned because it..."
  • Is anything else bothering you?*
  • Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*
  • Location of issue*
  • How does it feel?*
  • Whom else have you seen for this episode?*
  • "I am concerned because it..."

  • Health History

  • Do you exercise?

  • Blank fields will be assumed to be "none"

  • Please read the entire message on the next page, it is very important.

  • 🚨Very Important‼️🚨

    After clicking/tapping the "Submit" button, DO NOT CLOSE YOUR BROWSER. You will be redirected to your account page. Please login and complete the intake form. DO NOT "CREATE AN ACCOUNT". Login using the email address you gave us when we scheduled your appointment. 

    If you accessed this form directly from our website, or received an automated email by sending an appointment request, the intake form won't be available yet; we will manually send it to you.

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