Patient Information and Demographics

First Name*
Last Name*
Case Type*
Street Address*
Zip Code*
Martial Status*
Social Security #*
Referral Source*
Name of Friend/Family/Dr/Attorney/Internet Site*

Employer Information

Type of Work/Occupation


Preferred Language
Do You Exercise?
Do you smoke?
Emergency Contact & Phone #*

Reason for this visit

Is the purpose of this appointment related to:
If job related, have you made a report of your accident to your employer?
Have you been unable to work due to your condition?
Dates Out of Work?
If an Auto Injury, Have you contacted your insurance?*
Adjuster Name and Phone #?
Have you seen a chiropractor before?*
Chiropractor's Name and Date Last Seen
Have you seen other doctors for this condition?
Dr's Name and Treatment
Women: Are you pregnant?
Pregnancy Due Date
Treatment Goals (select any that apply)

Authorization for Care

I hereby authorize the Doctor to work with my condition through the use of Chiropractic adjustments, physical therapies and modalities, evaluations and X-rays as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payments. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

I understand that all appointments made must be rescheduled or cancelled within a 24 hours period, otherwise fees for that scheduled service will be charged to me and my account.

Patient's Signature

Health Conditions

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Health Conditions:
Treatment Contraindications*
Parents Health Conditions:

Vitals: Will Be Measured at Your Appointment

Blood Pressure:
Medications Currently Taken and Dosage:
Medications (Allergies and Reactions):
Surgeries and Year Performed:
Last Dr's Visit and Name:
Would You Like to Receive a Clinical Summary After Each Visit? (Dates, Service, Diagnosis, Meds, Allergies, etc.),
Date Signed *
Printed Name*
Email *

History of Current Condition

Primary Complaint (s):
When did this condition begin?
Was there anything that caused this symptom to start?
Has this condition
On a Scale of 1 (best) to 10 (worst) what is your discomfort?
Overall frequency of complaint ( choose one)
What is the QUALITY of your Symptom?
What Aggravates Your Symptoms?
What Relieves Your Symptoms?
Is it Interfering with Daly Activities?
Overall intensity of complaint (choose one)
Signature *
Date Signed*
Printed Name *
Email *