DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN:
Is this?
Current complaint (how you feel today):
How often are your symptoms present?
In the past week, how much has your pain interfered with your daily activities (e g, work, social activities, or housenold chores?
In general would you say your overall heaith right now is:
HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN FOR YOUR AREA(S) OF COMPLAINT?
Please check all of the following that apply to you:
Abnormal Weight
Family History:
I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is
not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am
liabie for all charges for services rendered and I agree to notify this practitioner immediately whenever I have
changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to
contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to
contact my physician, if necessary.
