Patient Intake FormWhat to expect from your first visitPlease enable JavaScript in your browser to complete this form.Name / Referral SourceName *FirstMiddleLastGenderMaleFemaleAgeBirth DateDateTimeHeightWeightAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell PhoneSocial Security#Email address *OccupationBusiness/Employer NameMarital StatusMarriedSingleWidowDivorcedEmergency ContactRelationshipEmergency Phone NumberCan the Dr. communicate with you via Email / TextYesNoHow many Surgeries have you had in the last 5 years?NoneLess than 5More than 5More than 10Have you had previous Chiropractic care?Have you had previous Chiropractic care?NoYesHow long ago?Medications You’re TakingPlease Mark the Areas of Concern BelowAllergies/AsthmaKnee PainAnxiety/DepressionLoss of balanceArthritisMenstrual IrregularityBack/Neck/Headache painMood SwingsCancerNervousnessCold feetNeuropathyCold handsNumbness/tinglingDigestive problemsOsteoporosisDizzinessPins & needlesFatigueSciaticaHeartburn/Acid refluxHeart conditionImmune System DisordersOther:Please check all of the following health concerns that you have experienced in the last five years, even if you think that your answers do not relate to your present concern.Other ?Checkboxes *I do hereby certify that the preceding questions have been answered truthfully and completely to the best of my knowledge and belief. I understand that I may be examined and treated by a licensed doctor, and that the treatment I receive shall be given as outlined by the doctor in charge of my caseSubmit
