New Patient Form

Symptom #1

Symptom #2

Symptom #3

If you are experiencing more than 3 different Symptoms, please consult further at your initial consultation

Physical

Current Medicines and Supplements

Please list any medications/drugs (prescription and non-prescription) - this includes Oral Contraceptive Pill, painkillers, chemotherapies, blood pressure medications, aspirin etc.

Mental and Emotional Stressors

Have you experienced any of the following in the last five years?

Systems Review

Are you currently experiencing any problems with the following? (tick)

1. Tell us about your pregnancy:

2. Tell us about the delivery and birth of this child:

3. Tell us more:

Acknowledgements:

To set clear expectations, improve communications and help you get the best results in the appropriate amount of time, please read each statement and sign below:

1. I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my child's health. I understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct spinal misalignments/nerve stress (vertebral subluxations). Chiropractic is a separate healing art from medicine and does not proclaim to cure any names disease or entity.
   
   
2. I grant permission to be called, texted, and/or emailed to confirm or reschedule an appointment and to be sent occasional cards, letters, emails, or health information as an extension of my care in this office.
   
   
3. To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my child's health concern(s).