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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

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

Separated 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?__________________________________

Application  
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