• Health Form

  • FINANCIAL
  • Dateof birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • MARITAL STATUS
  • Format: (000) 000-0000.
  • GENDER
  • Format: (000) 000-0000.
  • SPOUSE/ PARENT DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • DOB OF INSURED
     - -
    2 digit month, 2 digit day, 4 digit year

  • EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • HIPPA/MEDICAL INFORMATION RELEAŞE

  • I am aware of the Health Insurance Portability and Accountability Act, and by signing below l am authorizing any of my health records/ information may be disclosed to the following friends and/or family members
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • List present complaints in the order of what bothers you most
  • Format: (000) 000-0000.
  • Have you had chiropractic in the past?
  • What surgery have you had?
  • List any significant injuries (slips, falls, accidents, sports injury, and auto accident):
  • List Fractures/Broken Bones
  • Rows
  • Date of last Mammogram
     - -
    2 digit month, 2 digit day, 4 digit year
  • Smoker
  • Former smoker
  • Date you quit?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Family History
  • Select any of the following you have experienced

  • MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE DESCRIBED SENSATIONS. USE THE APPROPRIATE SYMBOL. INCLUDE ALL AFFECTED AREAS.

    Numbness +++++
    Pins and needles 00000
    Burning XXXXX
    Stabbing pain (Sharp) =====
    Aching pain (Dull)  ////// 
  • Mark On Image

  • CHECK ANY OF THE FOLLOWING YOU HAVE OR HAVE HAD IN THE PAST FIVE YEARS

  • GENERAL SYMPTOMS
  • RESPIRATORY
  • GENITOURINARY
  • EYES, EARS, NOSE AND THROAT
  • CARDIO-VASCULAR
  • GASTROINTESTINAL
  • SKIN
  • MUSCLE AND JOINT
  • FEMALE ONLY
  • Should be Empty: