Intake Form

Date
How did you hear about us?
Have you been seen here before?
Last Name
First Name
MI
Social Security #
Address
City
State
Zip
Home#
Cell#
Work#
Birth Date
Age
Male Or Female
No. of Children
Email Address
 Married Single Divorced Widowed
Employer
Occupation
Person to Contact in Case of Emergency
Relationship
Contact#
Previous Chiropractic Care? Yes No
Doctor’s Name

Please fill out if you are here as a result of a traffic accident:

Date of Accident
Driver
Passenger
City and State of Accident
 City Police State Trooper
Did you go to the hospital? Yes No
Which Hospital?
Where X-rays taken?  Yes No
Have you see an attorney?  Yes No
Name of attorney

Personal Auto Insurance

Insurance Co
Insured’s Name
Policy No
Medical Payments  Yes No

Other Drivers Insurance

Insurance Co
Insured’s Name
Claim No
Driver’s Name

Past History:

Pacemaker Yes No
High Blood Pressure Yes No
Diabetes  Yes No
Other serious health conditions, fractures, or surgeries: