New Patient Health History Form

To The New Patient Outline of Procedures For Care

Step One: All new patients are requested to fill out this personal health history questionnaire.
Step Two: A one-on-one consultation with the doctor will be done to discuss your health problems and to determine what may be the cause.
Step Three: A comprehensive examination and evaluation including those tests necessary to determined the precise cause of your problem is given.
Step Four: The doctors will advise you if additional laboratory tests or x-rays are needed.
Step Five: You will be given a Report of Findings at which time the cause of your problem will be discussed. It includes a thorough explanation of our treatment recommendations and what results can be obtained. You will also advised concerning how our office procedures work.
Step Six: If you are accepted as a patient, care will begin. Additional explanations will be given on the different types of treatments that are available in the office.
Step Seven: An estimate of the future care that is needed will be given and upon your acceptance, care will continue until the personal maximum correction of your problem has been obtained.
Step Eight: After maximum correction has been obtained, a schedule of care will be recommended to help prevent future problems and maintain good health.

Personal History

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Sex
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Who is Responsible For Your Bill?
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Other Doctors Seen For This Condition:
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Has This Condition Occurred Before?
Is Condition
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Have You Made A Report of Your Accident To Your Employer
Drugs You Take
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Do You Wear A Shoe Lift?
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Please Check and Describe
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Previous Chiropractic Care
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Intake
Have you been tested HIV positive?
Musculo-Skeletal Code
Genito-Urinary Code
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Are you pregnant?
Nervous System Code
C-V-R Code
General Code
EENT code
Gastro-Intestinal Code
Male/Female Code
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Family History
Please check the type of care desired so that we may guided by your wishes whenever possible.
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Please do not submit any Protected Health Information (PHI).

Location

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Office Hours

Monday  

9:00 am - 1:00 pm

3:00 pm - 6:30 pm

Tuesday  

Closed

3:00 pm - 6:30 pm

Wednesday  

9:00 am - 1:00 pm

3:00 pm - 6:30 pm

Thursday  

9:00 am - 1:00 pm

Closed

Friday  

9:00 am - 1:00 pm

3:00 pm - 6:30 pm

Saturday  

Closed

Sunday  

Closed