First Name:    
Last Name:     
Cell Phone:    
Home Phone:    
Email Address: 
Website/Facebook (Optional): 

Primary reason for consulting our office?

Any other associated complaints?

How long has this been going on?

Days   
Months 
Years  

Any previous incidents in your life?

Optional*

What is your one worst complaint?

Describe it: -- Please select -- Sharp Dull Travels Constant On & Off

Since the onset is it: -- Please select -- Better Worse The Same

Is there anything that makes it worse? -- Please select -- Standing Sitting Lying Motion

Are any of your systems involved?
Digestive Cardiovascular Respiratory
Elimination Reproductive

Does the pain cause you to:
Loose Sleep Be Short Tempered Miss Work
Miss Play Lose Focus

Any other facts about your current problem or pain?

Please check all your symptoms even if not seemingly related to your complaint:

Headaches Numbness in Fingers Numbness in Toes
Problem Urinating Mood Swings Sleeping Problems
Stomach Upsets Loss of Balance Pins & Needles in Legs
Pins & Needles in Arms Light Bothers Eyes
Menstrual Irregularity Buzzing in Ears Ringing in Ears
Loss of Smell Loss of Taste Back Pain Dizziness
Irritability Diarrhea Heartburn Fevers Fainting
Nervousness Cold Feet Neck Pain Tension
Hot Flashes Cold Hands Fatigue Depression Ulcers

Do you currently have health insurance that covers Chiropractic? -- Please select -- Yes No Not Sure

* This information is not required, but may help in diagnosing the issues surrounding your complaints, and can save time on paperwork when you visit our office.