New Patient Intake Form

Please use the form below to help us expedite your first visit to our office.

Tell Us About You

Your First and Last Name:
Street Address:
City:
State:
Zip:
Home Area Code & Phone:
Cell Area Code & Phone:
Work Area Code & Phone:
E-mail Address:
Confirm E-mail Address:
Personal Status: Minor   Single   Married
Divorced   Separated   Widowed
Date of Birth:
Age:
Gender: Male   Female
Referred By:
Occupation:
Spouse Name:
Children: Name                               Age                            Health Status
Give your children's health a letter grade.     A   B   C   D   F
A = Excellent health          A   B   C   D   F
B = Good health          A   B   C   D   F
C = Average health          A   B   C   D   F
D = Poor health          A   B   C   D   F
F = Failing health          A   B   C   D   F
    A   B   C   D   F
Have your children been checked by a chiropractor? Yes   No
Contact Person:
Contact Home Area Code & Phone:
Contact Work Area Code & Phone:

Health Information

What is your main concern?
What are your expectations?
How many glasses of water do you drink each day?
List your medications:
Surgeries and Dates:
What do you do to keep yourself healthy?
Family Health History:
Do you smoke?
Yes   No
If so, why?
Have you been to a Chiropractor before?
Yes   No
If so, what is the date of your last visit?

Rate Your Stress

Choose a number to rate each:
1=min., 10=max.
Physical Stress (ie. heavy lifting, excessive driving, computer work)       
1   2   3   4   5   6   7   8   9   10  
Chemical Stress (ie. exposure of toxins, medications, poor nutrition)       
1   2   3   4   5   6   7   8   9   10  
Emotional Stress (ie. work, family, financial)       
1   2   3   4   5   6   7   8   9   10  
List major stresses:
List major traumas or accidents and dates:

For Women

Are you taking birth control pills? Yes   No
Are you pregnant? Yes   No
If so, what is your due date?
Number of Pregnancies:
Number of Births:
Vaginal Deliveries:
C-Section Deliveries:
Have you entered menopause? Yes   No
If so, when?
Have you had a hysterectomy? Yes   No
If so, when?

Terms of Acceptance

When a person seeks chiropractic health care and we accept a person for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of
      vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental, and social well being, not merely the absence of disease
      or infirmity.

Vertebral Subluxation: A misalignment of one of the 24 vertebra in the spinal column that causes
      alteration of nerve function and interference to the transmission of mental impulses, resulting
      in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

HIPAA Privacy Practices
I authorize my health care provider to use a telephone system and / or email to use my name, address and phone number, the name of my schedules treating chiropractor, and the time and place of my schedules appointment(s) for the limited purpose of contacting me to notify me of a pending appointment or other health related communications. I also authorize my health care provider to disclose to third parties who answer my phone limited protected health care information regarding pending appointments and to leave a reminder message on my voice mail system and / or answering machine.

I, , have read and agree to the above HIPAA compliance statement.

Date:

Consent to evaluate and adjust a minor child

I, , being the parent or legal guardian of , have read and fully understand the Terms of Acceptance and hereby grant permission for my child to receive chiropractic care.
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