Tell us about yourself.

 
 


PATIENT INFORMATION
Name *
Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Sex
EMPLOYMENT INFORMATION
EMERGENCY CONTACT
Phone 2
Phone 2
CURRENT HEALTH CONDITION
MEDICATION, HERBS, SUPPLEMENTS
LIFESTYLE
Tobacco
Recreational Drugs?
PAST HEALTH HISTORY
Please report any past health conditions that may affect a proper diagnosis.
Major Surgeries or Operations
Broken Bones
Major Falls or Accidents
Hospitalizations
Previous Chiropractic Care
Review of Systems
(check all that apply)
Diseases
Genitourinary
Male/Female
Musculoskeletal
Nervous System
Gastro-intestinal
Cardiovascular
EEN
Is there a possibility that you might be pregnant?
Consent for Treatment and Insurance Authorization
I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of Chiropractic at In Motion Sports and Family Chiropractic. I hereby assign benefits and I Understand that payment is due as services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company(excluding contractual allowance).if, after 60 days, insurance payment has not been received. I understand that the charges are my responsibility and payable immediately. Additionally, I consent to treatment as deemed necessary by the Doctor of Chiropractic at In Motion Sports and Family Chiropractic
I acknowledge, I have seen, I have access to, and agree to :