HEALTH QUESTIONNAIRE

Please fill out the following questionnaire so we can get an idea of your current health condition. We can contact you via phone or email to discuss your options as well as schedule and appointment for a consultation and examination.

Questions about health insurance coverage?
We will gladly contact your health insurance company to determine the extent of chiropractic health coverage you have with our office. Simply include the information in the appropriate form fields below. (note: there are no out of pocket expense for most work-related and automobile accident injuries.)

Your confidentiality is important to us
Any and all information submitted is and will remain confidential.

Check any of the following symptoms that apply to you:
Back or neck pain, stiffness, soreness Chronic pain
Headache Painful joints
Pain between the shoulder blades Excess stress
Muscular spasm and tightness Dizziness or loss of balance
Pain, numbness or tingling in extremities Low energy and sluggishness
Over the last 12 months have you been involved in:
Auto injuries Work injuries
Sports injuries Other injury
If 'other injury", please explain
How has your health condition impacted your life?
What health goals have you set for yourself recently or would you now like to set?
To initiate or improve upon a fitness/exercise program To lose excess body fat
To build extra muscle To consume a healthier, more nutritious diet
To participate in a preventative health plan to increase overall health and well-being Other:
Place questions and concerns you would like to ask the doctor here:
Complete the area below if you would like us to check your insurance coverage:
Health insurance company
Phone number
If the information on your health card does not match the above or there is additional information, please include it below:
Personal Information
Name Address  
Email   City  
Phone   State  
Age      Zip  
Gender