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Health Questionnaire

Give Us a Head Start on Your Health Condition
To give us an idea of your current state of health, please fill out the form below. Indicate on the form if you would like to be contacted by phone or via e-mail to discuss your health care needs and possibly set up a visit to our clinic for consultation and examination.

Health Insurance Inquires
If you have questions regarding your health care coverage with our clinic, provide your insurance information below. We will let you know the extent of the coverage provided to you by your insurance company. (note: There are typically no out of pocket expenses for most work-related & automobile accident injuries.)

Please note that 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 & Sluggishness

Over the last 12 months have you been involved in any of the following?
Automobile Accident
Sporting Injury/Accident		 Work Related Injury/Accident
Other Injury/Accident (Please explain below)

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

What health or wellness goals have you set or would now like to set for yourself?
To initiate or improve upon a fitness/exercise program
To consume a healthier, more nutritious diet
To lose excess body fat		 A plan to increase overall health & well-being
To build extra muscle
Other (please explain below) 

Please place any other questions or concerns you have for the doctor below:

Insurance Coverage: (Please fill out this portion if you would like for us to check your insurance coverage)
Your Health Insurance Provider:
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 list it below:

Your Information: (all fields in bold are required)
Name:
Street Address:
City:   State:   Zip:
E-mail:
Home Telephone:
Work Telephone:
Age:
Sex:

What is the best way to contact you?
Please rate our site:

Do You Have A Work Or Accident Related Injury?
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