Today's Date
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MM
DD
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Name
*
First Name
Last Name
Your Date of Birth
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MM
DD
YYYY
Your Age
*
(please select)
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Your Sex
(please select)
male
female
non-binary
other
Datails regarding your sex, gender, preferred pronouns, etc. (optional)
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mailing Address (if differet from home address)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone #
*
(###)
###
####
Primary Phone # is your
(please select one)
cell
home
work
other
2nd Phone # (Optional), i.e. Home or Work
(###)
###
####
Secondary Phone # is your
(please select one)
cell
home
work
other
Email
*
Please confirm your e-mail (re-enter) here:
*
How did you hear about our office?
(select one)
referred by a friend, partner or family member
referred by a doctor or specialist
co-worker or company event
web search
noticed office while walking or driving by
coupon or promotional web site
local community event
- other -
Name of Person who Referred you to our office (if applicable)
First Name
Last Name
Employment (please check all that apply)
Your Current Occupation
Name of Your Company or Employer
Name of an Emergency Contact Person
*
First Name
Last Name
Your Emergency Contact Person's Phone Number
*
(###)
###
####
Your Emergency Contact Person's Phone Number is their
(please select one)
cell
home
work
other
Emergency Contact Person's Relation to You
(please select one)
boyfriend
co-worker
father
fiance
friend
girlfriend
husband
mother
neighbor
parent
partner
relative
roommate
sibling
spouse
wife
- other -
In seeking care at iHeart Chiropractic I am interested in (please check all that apply):
Health History
Please check the box in front of ALL conditions below that you have had now or in the past six (6) months:
Do you have any FOREIGN DEVICES inside of you? (such as metal plates, surgical screws or rods, etc.)
Do you have a (heart) pacemaker device?
Is the reason for today's visit due to an AUTOMOBILE ACCIDENT?
Do you currently have an open or pending INDUSTRIAL INJURY claim? (worker's compensation)
Have you ever had an INDUSTRIAL INJURY claim (work comp) in the past?
Have you experienced a recent accident, injury or trauma (within the last few months)?
Have you ever been diagnosed with a scoliosis (a sideways curvature of your spine)?
Have you ever had back surgery (in your neck, mid or lower back region)?
Have you ever been diagnosed with "Osteoporosis" (thin, frail or fragile bones)?
Are you currently (or have you been) expeiencing any pain in your stomach or chest region, that you do not know why it is/has been occurring?
Current Symptoms
Please check any of the following symptoms that you currently have or that you have had in the past six (6) months:
If you have been experiencing any symptoms in addition to those listed above, please list your additional symptoms in the box below.
Electronic Sugnature Consent:
*
