Adult Intake Form

Patient Name *
Patient Name
Phone
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. *
Is this due to an accident? *
If yes, when did the accident occur?
If yes, when did the accident occur?
Type of accident:
Describe your pain/discomfort. *
When is it worst? *
Please provide the name of any other doctor you have seen for this problem. *
Please provide the name of any other doctor you have seen for this problem.
What have you done that relieves your pain? *
Have you had any past surgeries or procedures? *
If female, is it possible you are pregnant?
How many accidents or fender benders have you been in? *
Have you ever been involved in sports? *
Have you ever...? *
Do you...? *
How did you find us?