Get In Touch With Us

PATIENT HEALTH HISTORY

Please write legibly to avoid inaccuracies and delays when processing your information.

Pain Symptoms: (In Order of Severity)

 Please LQGLFDWH areas of pain or discomfort and mark them using the codes listed below:

N=Numbness, T=Tingling, B=Burning, P=Pain, S=Soreness, A=Ache, SB=Stabbing, SF=Stiffness, X=Scars

List the frequency and severity of your condition on a scale of 1 to 5:

If you are currently under the care of a health care practitioner for any conditions or injuries, please provide their:

Please describe your lifestyle (please check):

List prescribed and over-the-counter pharmaceutical medication taken in the last 2 months:

Please describe your health history (please check).

Please use the point scales to rate your symptoms over the past 3 months.

1 = Occasional, Not Severe 2 = Occasional, Severe 3 = Frequent, Not Severe 4 = Frequent, Severe

Digestive Tract

General

Respiratory

Urinary

Weight & Eating

Musculoskeletal

Cardiovascular

Emotions

Mind

Neurological

Energy & Activity

Ears

Nose

Eyes

Head

Sleep

Mouth & Throat

Skin & Hair

For Women Only

Operations and Procedures

I understand and agree that health and accident insurance policies are an arrangement between the insurance company

and me. The heath care provider’s office will prepare necessary paperwork to assist me in the filling insurance claims but cannot

guarantee reimbursement. Direct payments made from the insurance company to the health care provider’s office will be

credited to my account upon receipt and any balances due will be my responsibility. All services rendered to me are my personal

responsibility and I agree to make payments for these services to the health care provider’s office. I also understand that if I

suspend or terminate my care and treatment, any fees for services rendered will be immediately due and payable. Should third

party collection become necessary, I agree to pay all fees involved in collections of the account.

I authorize the health care provider to examine and treat my condition as deemed appropriate through the use of

chiropractic care, acupuncture, Traditional Chinese Medicine, and/or other natural healing methods.