Health Pass

This gift certificate below entitles you to a comprehensive consultation, spinal examination, spinal imaging and a report of findings for only $60.00. This valuable offer is your first step towards better health.

Our Gift Of Health To You For Only $60

(Valued at $85.00)

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Health History

Name

Address

HOME PHONE

CELL PHONE

BIRTHDATE

ARE YOU EMPLOYED OR A STUDENT?

MARITAL STATUS

EMERGENCY CONTACT NAME/PHONE

HOW DID YOU HEAR ABOUT OUR OFFICE?

PLEASE LIST YOUR CURRENT MEDICATIONS

HAVE YOU HAD XRAYS/MRI/CT ON YOUR SPINE IN THE LAST 5 YEARS?

YESNO

HAVE YOU EVER HAD CHIROPRACTIC CARE BEFORE? IF YES, WHEN AND WHERE WAS YOUR LAST ADJUSTMENT?

ARE YOU RECEIVING CARE FROM OTHER HEALTH PROFESSIONALS? (IE: MASSAGE, PHYSIO) WHAT TYPE OF TREATMENT HAVE YOU TRIED?

ARE YOU PREGNANT? IF YES, HOW FAR ALONG ARE YOU?

NAME OF FAMILY PHYSICIAN

CURRENT COMPLAINT

WHEN DID THIS BEGIN?

IS IT

GETTING WORSEIMPROVINGINTERMITTENTCONSTANT

DO YOU HAVE:

IS YOUR PAIN:

SHARPDULLTHROBBINGCAN'T SAY

ARE YOUR SYMPTOMS AFFECTED BY:

DO YOUR SYMPTOMS INTERFERE WITH:

DO YOU EXPERIENCE SYMPTOMS:

DAILYWEEKLYMONTHLYCAN'T SAY

HOW LONG DO SYMPTOMS LAST?

ON A SCALE OF 1-10 (1 LEAST, 10 MOST) PLEASE RATE THE SEVERITY OF YOUR PAIN (1 PAIN LEVEL)

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS?

HAVE YOU SUFFERED FROM (PLEASE CHECK ALL THAT APPLY)

PAST INJURIES CAN AFFECT PRESENT HEALTH. PLEASE CHECK ALL THAT APPLY

WE DO NOT DIRECT BILL. DO YOU HAVE INSURANCE? IF YES, WHAT IS THE COMPANY AND YOUR YEARLY COVERAGE?

OFFICE USE ONLY

HEALTH HISTORY HAS BEEN REVIEWED AND DISCUSSEDPATIENT CONSENTED TO EXAMINATION

This gift certificate below entitles you to a comprehensive consultation, spinal examination, spinal imaging and a report of findings for only $60.00. This valuable offer is your first step towards better health.

Our Gift Of Health To You For Only $60

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