Patient Name *

First Name

Last Name

Phone

(###)

###

####

Are you seeking wellness care? If you have no current area of concern but choose chiropractic care for your health, please select yes. Otherwise, select no. *

Yes

No

Is this due to an accident? *

Yes

No

If yes, when did the accident occur?

MM

DD

YYYY

Type of accident:

Auto

Home

Work

Other

Describe your pain/discomfort. *

Sharp

Dull

Throbbing

Burning

Numbness

Achy

No pain

When is it worst? *

Morning

Afternoon

Evening

After a specific activity

Wakes me up at night

No pain

Please provide the name of any other doctor you have seen for this problem. *

First Name

Last Name

What have you done that relieves your pain? *

Ice

Heat

Chiropractic Care

Massage

Medication

No pain

Have you had any past surgeries or procedures? *

Yes

No

If female, is it possible you are pregnant?

Yes

No

How many accidents or fender benders have you been in? *

5+

3-4

1-2

None

Have you ever been involved in sports? *

Yes

No

Have you ever...? *

Fallen down the stairs

Slipped/fell on the ground (or ice)

Had a sport injury

Broken a bone

None of the above

Do you...? *

Sit more than 4 hours per day

Drive more than 2 hours per day

Perform repetitive tasks (i.e. typing, lifting, bending, etc.)

No repetitive activites

How did you find us?

Facebook

Instagram

Google

Patient

BNI

Event

None of the Above