To expedite your first visit, please fill out this form, hit send and call 954-564-3200 to schedule your initial visit.   First Name: Last Name: Address: City: State: Zip: Home Phone: Work Phone: Date of Birth: 01 02 03 04 05 06 07 08 09 10 11 12 / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 S.S.#: Marital Status: Married Single Widowed Divorced Separated Num. of Children: 1 2 3 4 5 6 7 8 9 10 Ages: Occupation: Employer: How were you referred to our office? Main Complaint: How Long: Other Complaint: How Long: Did this occur at work?   Yes No When? Was this due to an auto accident? Yes No When? Have you had this problem before? Yes No When? What do you think is causing it? Is this worse when: Sitting Standing Running Walking Morning Night Mid-day All Day Have you ever had chiropractic care? Yes No When? What Condition? By Whom? Do you have health insurance? Yes No Provider? (on back of insurance card) Member ID:   Phone: Date of last physical exam:   01 02 03 04 05 06 07 08 09 10 11 12 / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 Females: Are you pregnant?   Yes   No   Maybe Have you ever suffered from: Backaches Heart trouble Dizziness Diabetes Arthritis Digestive disorders Asthma Headaches Neck pain Nervousness Neuritis Sinus trouble Sciatica Other Explain: Family Health Information: (Many health problems are the result of heredity spinal weaknesses. Thus, information about your family members will give us a better picture of your overall health) NAME RELATION PAST & PRESENT PROBLEMS I am interested in: Relief     Releif & Strengthening     Releif, Strengthening & Improved Health   Please speak freely and openly to our staff and doctors so we may better serve you. I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Chiropractic Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Chiropractic Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.
© 2010 Galt Mile Wellness Chiropractic Center - All rights reserved.