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Health Questionnaire

Give Us A Head Start On Your Health Condition
Fill out our Health Questionnaire below to give us a head start on your current health condition. When you're done, simply indicate whether you'd like us to contact you by phone or e-mail to discuss your health plan options as well as explore the possibility of scheduling you for a consultation and examination.

Health Insurance Coverage Questions?
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
	Headaches
	Pain between the Shoulder Blades
	Muscular Spasm and Tightness
	Pain, Numbness or Tingling in Extremities

	Chronic Pain
	Painful Joints
	Excess Stress
	Dizziness or Loss of Balance
	Low Energy and Sluggishness

Over the last 12 months have you been involved in: select all that apply

	Auto Injuries
	Other Injury

Work Injuries

Sports Injuries

If "Other Injury", please Explain:

How has your health condition impacted your life? i.e. prevented you from doing?

What health goals have you set for yourself recently or would you now like to set? check all that apply

	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:
	Subscriber ID:
	Group or Plan Number:
	Phone Number:
	If the information on your health card does not match the above or there is additional information, please include it below:

Give us some information about yourself.
*	Name:
	Street Address:
*	City:	* State		Zip:
*	E-Mail:
*	Telephone:
*	Age:		male female

*	How Should We Contact You? Home Telephone Work Telephone E-Mail



* required information

Health Questionnaire

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