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: