Please complete the form below

Name *
Name
Street, City, State, and Zip
Sex *
Marital Status *
Are you a veteran or active military? *
Have you been hospitalized within the past six months?
Have you had a complete spinal examination (including films) within the past year? *
Have you ever been to a chiropractor before? *
If you answered yes, how was your experience?
How did you hear about our office (please check all that apply)? *
How do you prefer we contact you to schedule your consultation and examination? *
Is your reason/injury/condition related to an auto accident or work related injury? *
Date of Onset (when did it begin) *
Date of Onset (when did it begin)
How often do you experience the pain? *
What time of day is the problem the worst? *
Does the pain/discomfort radiate into your extremities? *
Date of Onset
Date of Onset
How often do you experience the pain/discomfort?
What time of day is the problem the worst?
Does the pain/discomfort radiate into your extremities?
Date of Onset
Date of Onset
How often do you experience the pain/discomfort?
What time of day is the problem the worst?
Does the pain/discomfort radiate into your extremities?
Have you (in the past or currently) received care for this condition? *
In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
Head *
Neck *
Shoulders *
Arms and Hands *
Middle Back *
Lower Back *
If present check all that apply: "Pain is worse when"
Hips, Legs and Feet *
Gastro-Intestinal Issues *
Are you pregnant? *
Are you trying to become pregnant?
If yes, have you had trouble conceiving?
Please identify how your current condition is affecting your ability to perform normal activities of daily living.
Changing Positions (example: sit to stand) *
Walking *
Climbing Stairs *
Household Chores *
Yard Work *
Carrying Groceries *
Caring for your pet(s) *
Caring for Children *
Operating a Vehicle *
Using the Computer *
Reading *
Concentrating *
Bathing Yourself *
Dressing Yourself *
Shaving/Grooming *
Being Intimate/Sexual Activities *
Sleeping *
Have you suffered with this pain/symptom/condition/injury/illness in the past? *
If no surgeries in past say "none"
If no broken bones say "none"
If no major illnesses say "none"
Has anyone in your family suffer with or is currently suffering with similar condition(s)? *
If yes whom?
Are there any hereditary conditions that the doctor should be made aware of? *
Do you smoke (cigarettes, cigars, pipe)? *
Do you consume alcoholic beverages? *
Do you use marijuana? *
Do you use drugs recreationally (Example: cocaine, methamphetamines)? *
What position do you typically sleep in? *
List "none" if not currently taking any medications
If you wish for our office to verify your insurance benefits, please provide us with the following information.
Do you wish to utilize insurance? *