Doctor of Chiropractic
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Patient Intake Form
*Name:
*Sex
-Select a choice-
Male
Female
*DOB:
*Address:
*Phone#:
*Occupation/Employer's Name
*Status
-Select a choice-
single
married
divorced
widowed
*Reason for consulting our office?
*Who may we thank for referring you to our office?
Do you smoke/drink alcohol?
Yes
No
*Did you ever have any serious falls, accidents, or sports injuries as a child or adult?
Yes
No
Unsure
*Any history of major or minor surgeries?
*On a scale of 0-10 Describe your stress level:
-Select a choice-
1
2
3
4
5
6
7
8
9
10
0
*In a brief statement how would you describe your diet, exercise, and sleeping habits?