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

    MarriedSingleDivorcedWidowed

    Employer

    Occupation

    Person to Contact in Case of Emergency

    Relationship

    Contact#

    Previous Chiropractic Care?YesNo

    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 PoliceState Trooper

    Did you go to the hospital?YesNo

    Which Hospital?

    Where X-rays taken? YesNo

    Have you see an attorney? YesNo

    Name of attorney

    Personal Auto Insurance

    Insurance Co

    Insured’s Name

    Policy No

    Medical Payments YesNo

    Other Drivers Insurance

    Insurance Co

    Insured’s Name

    Claim No

    Driver’s Name

    Past History:

    PacemakerYesNo

    High Blood PressureYesNo

    Diabetes YesNo

    Other serious health conditions, fractures, or surgeries: