• Welcome

  • Please complete this confidential questionnaire. Your answers will help us determine if we can help you. Thank you.

  • Sex*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status*
  • Do You Have Health Insurance?*
  • 4. Have you had this or similar conditions before?*
  • 5. Did this condition start:*
  • 6. Is this condition getting:*
  • 7. Is this condition:*
  • 8. If you have pain, is it:*
  • 9. Does this condition affect your:*
  • 10. Is this condition worse at:*
  • 13. Is this condition interfering with your:*
  • 14. Is there anything you have tried yourself to relieve this condition, such as:*
  • 15. Have you seen any other doctors for this condition?*
  • 16. If you saw another doctor, did he treat you or prescribe anything for you?*
  • 18. Have others in your family had this or similar conditions?*
  • 19. List your accidents or injuries and the years you had them (If not applicable write N/A)*
  • 20. Please list any current medications (If not applicable write N/A)*
  • 22. Have you had any previous chiropractic care?*
  • 23. Have you ever had any mental or emotional disorders?*
  • 24. What type of service do you desire?*
  • HAVE YOU EVER:*
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  • DATE OF LAST: *
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  • I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will help prepare the necessary forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and/or treatment, any fees for services rendered me will be immediately due and payable.

    I hereby give permission to the doctor to administer treatment and perform such procedures as he may deem necessary in the diagnosis and/or treatment of my condition.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • IN CASE OF EMERGENCY: (Name of relative or close friend not living in home):

  • Format: (000) 000-0000.

  • GENERAL HEALTH HISTORY QUESTIONNAIRE

  • Please indicate your experience with each condition by use of the following codes: 
    1- Never Had
    2- Previously Had
    3- Presently Have

  • MUSCULO-SKELETAL SYSTEM*
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  • NERVOUS SYSTEM*
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  • GASTRO-INTESTINAL SYSTEM*
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  • SKIN *
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  • CARDIO-VASCULAR-RESPIRATORY*
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  • EYE, EAR, NOSE, AND THROAT*
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  • GENITO-URINARY SYSTEM*
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  • CHECK THE FOLLOWING CONDITIONS YOU HAVE HAD OR CURRENTLY HAVE:*
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  • For Female:

  • Are you Pregnant?*
  • FEMALE*
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  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Mark all the areas of the body where you feel the described sensations. Use the appropriate symbol. Include ALL AFFECTED AREAS.

  • Type: A = ACHE        B = BURNING       N = NUMBNESS     P = PINS & NEEDLES     S = STABBING    O = OTHER*
  • Should be Empty: