Application for Treatment

Name: ___________________________________________________ Date: _________________

DOB: __________________________________ Date of onset: ______________________________

Address: _________________________ City: ____________ State:_____ Zip code: _______

SS#:_________________ Home#:______________ Work#:______________ Cell#:_________________

Circle if you are: Married Divorced Widowed Single Separated

Referred to our office by: Yellow Pages Newspaper Flyer Radio Web Other_______

Who is responsible for your bill? Self Spouse Employer

How payment will be made: Cash Credit Card Check Health Insurance Workers Comp Auto Ins. Policy

Please indicate the location of your pain:

Please describe your major problems: ______________________________________________________________________________________________________________________________________How did this condition develop/how did it start? _____________________________________________________________________________________________________________________________Have you ever had this problem or something similar? Please explain: __________________________________________________________________________________________________________Have you received previous treatment for this condition? If yes, please state where/when/what were the results: ________________________________________________________________________________________________________________________________________________________Is the problem getting better/worse/staying the same? What makes your condition worse?________________________________________________________________________________________How has this condition affected your home/recreational/occupational/rest and sleep life?____________________________________________________________________________________

Any chiropractor consulted in the past? Y / N If so, please name:___________________Dates consulted:__________________ For what problem?__________________________________