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Confidential Health Survey
Fill in the following fields online and press "submit", or you may open the link below and print this form to bring to your first visit.

Intake_Form-2010.pdf

*indicates required fields

*First Name:

*Last Name:

*Date of birth:

*Gender:

Male
Female

*Marital status:

Single
Married
Divorced
Widowed

*Ages of children:

*Street Address:

*City:

*State:

*Zip code:

*Home phone:

Work phone:

Cell phone:

E-mail:

*Occupation:

Employer:

Spouse's first name:

*How did you choose our office?:

*What is your MAIN reason for contacting us?:

I am experiencing a symptom of a problem and would like to find out how you can help me
I am not experiencing a problem, but would like my current state of health to be evaluated
I am looking for continued chiropractic care to keep me well

*Please describe your health concerns you may have:

*List all medications (including OTC):

*List any surgeries:

*Approximate date of last spine x-rays:

*Previous Chiropractor's name:

*Health insurance?:

no insurance
BC/BS
Medicare
other

*Previous traumas:

Motor vehicle accident greater than 3 mph
Motor vehicle accident greater than 3 mph
Motor vehicle accident greater than 3 mph
Stress or strain related to work
Emotional trauma
Adult sports: stress/strains
Childhood injuries

*This survey is complete!:

I have already scheduled my evaluation
Please call me to schedule my appointment

After completing this form click on the SUBMIT button.

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