Completing this form accurately will ensure your patient information is collected and readily available upon your first contact with us. Your health history will help us to identify pre-conditions and provide you with the best chiropractic and health care options.

PATIENT INTAKE FORM

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Step 1 of 2

PATIENT INFORMATION

ARE YOU A STUDENT?

WHAT BRINGS YOU HERE?

Have you ever had chiropractic care before?
Are you receiving care from other health professionals?
Are you pregnant?
Have you had XRAYS/MRI on your spine within the last 5 years?
Is it:
Check the following joints that apply.
Headaches
Neck
Arm
Mid Back
Low Back
Buttock
Sciatic
Groin
Front Leg
Check the following areas that apply.
TMJ/Jaw Pain
Shoulder Pain
Elbow Pain
Wrist Pain
Hand/Finger Pain
Hip Pain
Knee Pain
Ankle Pain
Foot/Heel Pain