Welcome to our online Patient Intake Form. The information you fill in will be sent securely to our office, speed up your office visit, and will help us to better serve your heatlh care needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of the form.
For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.
First Name Middle Name Last Name
"Nick Name" or name you would like to be called if different:
Mailing Address:
City: State: Zip:
Cell Phone: Home Phone: Work Phone:
Email Address:
(We will not share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)
Date of Birth (MM/DD/YYYY): Gender: M F Relationship Status:
Spouse or Partner's Name: Number of Children:
Emergency Contact: Relationship: Phone:
Are you Self Employed? Yes No If yes, your company's name:
Regular Work Status:
Full time Part time Retired Unemployed
College Student Full time Part time
Employer's Name:
Employer's Address:
City: State: Zip:
Your Occupation:
Financially Responsible Party: Self Spouse Parent Other
Most patients are referred to our office by a caring family member or friend or other existing client. What made you decide to visit our office? Please check all sources that apply to your situation.
Friend/Family Member Existing Client
Network Practitioner Another Doctor/Practitioner
Network Practitioner's List Our Website Office Sign Flyer Welcome Wagon Ad Presentation
Facebook Google LinkedIn Meetup Pinterest Twitter Yelp YouTube Other
Your quality of life is our concern. Please complete this form by listing your health concerns (in order of priority) and rate the severity of each from 1-10 with 10 being the worst.
  1. Chief Physical Complaints
  2. Chief Emotional Complaints
  3. Please list any other concerns that you would like the doctor to know about:
  4. How do you feel about your current condition? (Please choose ONE that BEST describes how you feel.)
    I feel helpless; nothing works.
    I don't like what I am feeling, and I hope you can fix it.
    I feel this is a pattern that has happened to me before; it is back again.
    I feel there is a message my body is giving me.
    I am looking for assistance in becoming healthier so I can move past my health concern.
    I realize my condition may be a necessary experience in getting to the real problem.
    I don't know how I feel. I am too preoccupied with my present condition.
    I am looking for something to help me enhance my quality of life and further enhance my wellness.
  5. What would you like to accomplish from your healing process in our office?
The intent of this form is to assist you in your healing process by initiating a thoughtful recognition of your life experiences. Life is a cumulative process; use this form to increase your understanding and appreciation of your own life process and accumulation of stressors, both positive and negative.
Have you ever had your spine or nervous system examined professionally? Yes No
Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime?
Never Once Twice A few times Over 24 times I lost count and would not live without it
Do you know what type of adjustments the chiropractor performed, or what technique(s) or methods he or she used?
Were you pleased with his or her service? Yes No Comments
Has anyone ever taken x-rays of your spine? Yes No When?
Does anyone in your immediate family receive chiropractic adjustments? Yes No
Have you ever received Network Chiropractic / Network Spinal Analysis Care? Yes No
Who was or is your Network Practitioner? State:
If you are still in care, when was your last visit?
If you stopped, why did you stop?
How long did you receive care? How often did you go?
Does anyone in your immediate family receive Network (NSA) Care? Yes No
Have you had in the past or do you current participate in any of the following vehicles toward health, growth and personal development? (Check all that apply)
Life Coaching Massage Therapy Acupuncture Hypnotherapy EFT Meditation Yoga
Drumming Energy Medicine Oneness Blessing Somato Respiratory Integration (The 12 Stages of Healing)
Osteopathy Karate/Martial Arts Dance Craniosacral Therapy Homeopathy Psychotherapy
Other Movement or Exercise Rebirthing/Breathwork Reiki Prayer Other:
Comments or additional information
The practice of chiropractic is based upon the location and adjustment of Vertebral Subluxations. Spinal Subluxations are caused by any stress your body can not properly perceive, adapt or recover from. These stresses may be PHYSICAL, CHEMICAL, or EMOTIONAL / MENTAL in nature.
Often the first subluxation can be experienced at birth. Please complete these questions as thoroughly as possible based on any information you have or can obtain about your history.
BIRTH: Were there any problems associated with your mother's pregnancy with you? (Check all that apply)
Outwardly Ill Trauma Difficult Pregnancy Falls, Accidents or Physical Injuries Unusual Stress
Was your delivery? At Home In Hospital Natural Drug Induced C-Section Breech
Forceps/suction Prolonged labor Cord around neck Traumatic
Comments or additional information
TRAUMA RELATED MEDICAL INTERVENTIONS: Have you had any of the following? (Check all that apply)
hospitalization surgery organ removal spinal tap spinal injections physiotherapy neck collar
spinal brace traction special shoes orthotics heel lift radiation treatments blood transfusion
corrective shoes or bars on shoes extensive diagnotstic x-rays chemotherapy bone in cast or immobilized
Comments or additional information
FALLS: from crib tree bicycle steps skates on ice other Details:
VEHICULAR ACCIDENTS: Have you (even as a passenger and even if you do not think you were hurt) been involved in a collision or near collision? Please check all that apply and state approximate dates and severity (Mild, Moderate, Severe or Extreme).
automobile motorcycle bus train bicycle airplane mo-ped skateboard
Explain with Dates:
OTHER PHYSICAL TRAUMA: physical fight armed forces abuse knocked unconscious broken nose
extensive dental work childhood illness used crutches/cane broken bones other
Explain with Dates:
In the past I was active in sport(s)? Yes No Which one(s)?
I am currently active in sports? Yes No Which one(s)?
Have you been hurt in any of these activities? Yes No When?
Please explain:
Do you read for prolonged periods? Yes No Do you play a musical instrument? Yes No
Do you have a particular position for watching television or reading? Yes No
I wear: Glasses Bifocals Trifocals Contact lenses N/A Other
During the day, I: sit stand walk drive do desk work phone work mechanical work heavy lifting
I exercise: daily weekly monthly List Details:
An imbalance in the chemistry of the body can cause subluxations AND subluxations can cause an imblance in the chemistry of the body.
BIRTH: During your mother's pregnancy with you did she: (Check all that apply)
use prescription drugs use non-prescription drugs chemically induce labor consume alcohol smoke
Comments or additional information
Was your mother: Conscious Semiconscious Unconscious Under Spinal Anethesia during delivery?
Comments or additional information
OTHER CHEMICAL STRESSORS: Have you and your family members been vaccinated? Yes No
Do you or have you ever taken: prescription drugs over the counter drugs antibiotics other
Do you or have you ever worked with: chemicals fumes dust smoke
Do you consume: alcohol coffee/caffeine tobacco artificial sweeteners soda tap water
recreational drugs diet food refined sugar eggs cooked, canned vegetables raw vegetables
fresh fruit whole grains dairy fried foods beef poultry fish seafood organic foods
The type of diet I usually follow is classified as:
Medications are chemicals that can and may cause subluxations and imbalances in nervous system function. Are you now taking any drug (prescription or over-the-counter) regularly?
Drug: Date Prescribed: Reason:
Drug: Date Prescribed: Reason:
Drug: Date Prescribed: Reason:
Drug: Date Prescribed: Reason:
Drug: Date Prescribed: Reason:
Are these drugs being prescribed by a physician? Yes No Last visit:
If you were previously taking any other medication regularly, please describe:
Emotional and Mental stress can cause and/or accelerate spinal and nerve dysfunction leading to dis-ease.
BIRTH: My birth was: At home In a birthing center In a hospital Other
Were you incubated or isolated after birth? Yes No List Details
Were you: Bottle fed formula Bottle fed mother's milk Nursed Nursed and bottle fed
How do you grade your physical health? Excellent Good Fair poor Getting Better Getting Worse
Rate your emotional / mental health: Excellent Good Fair poor Getting Better Getting Worse
Rate your overall quality of life: Excellent Good Fair poor Getting Better Getting Worse
Please check all that apply and note their severity on a 1-10 scale (1 is the easiest and 10 the most difficult):
Childhood Stress Work Related Stress School Stress
Stress of Commuting Play or Recreational Loss of loved one
Family Stress Change in lifestyle Personal Relationships
Change in vocation Stress of being sick Abuse
Divorce / Separation Parents divorce Financial
Which are you most interested in? Crisis and emergency care Wellness and maintenance care
If we find subluxations in your spine, is there anything that might prevent you from following through with the doctor's recommendations? If so, please explain:
Research shows that people in care report changes in their physical state, mental emotional states, their body's ability to adapt to stresses, achieve a heightened quality of life and make positive lifestyle choices. Which of these would most excite you to share this work with your friends and family?
If you consider yourself ill, why do you feel you are ill?
If you consider yourself well, why do you feel you are well?
Is there anything else you wish to share, which has not been discussed, that may help us to better understand you and why you have chosen to see the doctor in this office?
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
* I agree with this statement of authorization