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Have you been a patient of ours before?
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2
Which of our offices did you have your most recent visit?
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Columbia IL 618-719-2350 www.ChiroPro.com
Glen Carbon IL 618-692-9100 www.ChiroPro.com
Highland IL www.ChiroPro.com
Lake St. Louis MO 636-614-2139 www.ChiroPro.com
Shiloh IL 618-234-8300 www.ShilohChiro.com
Columbia IL 618-719-2350 www.ChiroPro.com
Glen Carbon IL 618-692-9100 www.ChiroPro.com
Highland IL www.ChiroPro.com
Lake St. Louis MO 636-614-2139 www.ChiroPro.com
Shiloh IL 618-234-8300 www.ShilohChiro.com
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Legal First Name
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Middle Initial
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Last Name
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Phone Number
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Area Code
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Email
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Date of Birth
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Date
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Age
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Biological
sex
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Please use your biologic sex even if that is different than gender identity.
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Date of Last Menstrual Period
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If you do not have menstrual cycles, please describe below.
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Updates to Demographics (Marriage, Address, Phone, Doctor/Primary, etc.)
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13
Do you have any new injuries, accidents, diagnoses, medications or surgeries since your last visit? (explain)
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Has there been any major change to your family history such as heart attack, stroke, cancer, diabetes or other serious issues?
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15
What and Where is your problem?
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If you are just wanting a wellness / maintenance treatment, just type "Wellness"
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16
How long has it bothered you?
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17
Have you had this before?
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18
Explain
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19
What makes it better?
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20
What makes it worse?
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21
How bad is it? (Scale of 0-10)
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22
What does this prevent you from doing?
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Or how does it affect you?
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23
I agree that the information submitted is true to the best of my knowledge.
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I agree.
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