Patient Paperwork

For New and Existing Patients

Please correct the errors described below.

Emergency Contact Information:

(First, MI, Last)

Financial Information:

History of Present Illness (Please describe):

Major Complaint Details:

On a scale of 1-10
(Name, dosage, & frequency)
(Name and reaction)

Review of Systems:

Many of the following conditions respond to chiropractic treatment.

Are you CURRENTLY experiencing any of these symptoms? (Please select all that apply and us comments to elaborate)

Functional Rating Index:

In order you properly assess your condition, we must understand how much your condition has affected your ability to manage everyday activities.

For each item below, please select the number which most closely describes our condition right now.

Personal, Family, and Social History

Have you EVER had any of the following? (Please select all that apply and use comments to elaborate)


Family History:

Please select all that apply and use comments to elaborate.

Social and Occupational History:

Your information will be encrypted.