What is your full name? * As it appears on your ID, insurance card or medical record
What is your date of birth? *
What is your age?
What is your email address? * We'll keep you up to date with office news and announcements
What is your street address? *
What is your city and state? *
What is your postal or zip code? *
What is your phone number? * Enter the best available phone number to reach you.
Who were you referred by?
Will you be a medical insurance patient? YesNo
Please upload a picture of your insurance card:
What is the name of the primary insured ?
Is the name of the primary insured the same as the patient? YesNo
What is the name of the patient?
What is the name of your insurance company?
Please enter insurance customer service phone number
What is your insurance member ID number?
What is your group number?
Were you in an auto accident? YesNo
What was the date of your vehicle accident? Format Example: Month/Day/Year
What is the name of your auto insurance?
What is the phone number of your auto insurance?
What is the name of the Auto Insurance contact person?
Insurance: What is the claim or policy number?
*Please read the Auto Insurance legal notice and accept to continue.
I understand and agree that health/auto insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Have you ever been treated for any conditions in the last year? YesNo
Please describe the conditions you were treated for...
What is the date of your last physical exam? Format Example: Month/Day/Year
What is the date of your last blood work? Format Example: Month/Day/Year
Are you male or female?MaleFemale
Is there a chance that you may be pregnant? YesNo
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/ her associates have my permission to perform an X-ray evaluation if needed. I am aware that X-ray, CT or other diagnostic studies can be hazardous to an unborn child.
Have you had X-rays taken? YesNo
Where were the X-rays taken & approximate date?
Are you currently taking medications? YesNo
What medications are you currently taking and for what conditions? Please list dosage and amounts, etc. :
What vitamins, herbs or nutritional supplements do you currently take? Please list for what condition, dosage and frequency
Have you ever broken any bones? YesNo
Briefly explain:
Have you ever been hospitalized? YesNo
Have you ever been in an auto accident? YesNo
Have you ever been struck unconscious? YesNo
Have you ever had surgery? YesNo
How often do you drink alcohol? 01234Please be honest. Your answers are secure.
How often do you intake caffeine? 01234Please be honest. Your answers are secure.
How often do you smoke or vape tobacco? 01234Please be honest. Your answers are secure.
How often do you use drugs (prescribed or recreational)? 01234Please be honest. Your answers are secure.
How often do you exercise? 01234Please be honest. Your answers are secure.
How many hours do you normally sleep? 01234Please be honest. Your answers are secure.
How much water do you drink daily? 01234Please be honest. Your answers are secure.
How often do you eat sugary/sweet food & snacks? 01234Please be honest. Your answers are secure.
What is the nature of your injury?
When was the date your symptoms appeared? Format Example: Month/Day/Year
Have you had the same injury before? YesNo
Please name any other practitioners you've seen for your condition or injury.
Have you ever been under Acupuncture or Chiropractic care? AcupunctureChiropractic
Do you currently or have you suffered from any of the following: AllergiesAnemiaArthritisAsthma or BronchitisBack PainBreast LumpBone Density LossBruise EasilyCancerConstipationDepressionDiabetesDigestion ProblemsDizzinessTinnitus/Ears RingUnusual FatigueFrequent UrinationHeadachesHigh Blood PressureHot FlashesIrregular Heart BeatKidney Infection/StonesLoss of BalanceMid Back PainNeck Pain or StiffnessNosebleedsPacemakerPoor PostureProstate TroubleSciaticaSleep Problems/InsomniaSpinal CurvaturesStroke/Heart conditionSwelling of AnklesThyroid ConditionUlcers
Do you experience pain or symptoms every day? YesNo
Do your symptoms interfere with daily life? Please explain briefly:
Are your symptoms worse during certain times of the day? YesNo
Briefly explain…
Do changes in weather affect your symptoms? YesNo
Do you wear foot orthopedics? YesNo
What activities aggravate your symptoms?
What area is bothering you? Please select your body's region. HeadNeckShoulder (Right)Shoulder (Left)Elbow (Right)Elbow (Left)Wrist (Right)Wrist (Left)Hand (Right)Hand (Left)Hip (Right)Hip (Left)Knee (Right)Knee (Left)Ankle (Right)Ankle (Left)Foot (Right)Foot (Left)Leg (Right)Leg (Left)Back (Upper)Back (Mid)Back (Lower)
What type of pain is this causing you? PainLoss of Use/MovementAltered Sensation
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