Please fill out this form as completely and accurately as possible. All the information requested below is necessary for us to serve you the best way possible.

PERSONAL INFORMATION

Is this concern affecting your quality of life?

HEALTHCARE HISTORY

FOR WOMEN

HEALTH, WELLNESS AND CHIROPRACTIC CARE

The human body is designed to be healthy. The primary system in the body which coordinates health is the NERVOUS SYSTEM. The vertebrae surround and protect the delicate NERVOUS SYSTEM.

Physical, emotional, and chemical stresses, common to our contemporary lifestyles, can result in misalignment to the spinal column as well as damage to the nervous system. The result is a condition called VERTEBRAL SUBLUXATION. The chiropractic exam/evaluation determines if your spine shows signs of VERTEBRAL SUBLUXATION

History of Physical Stress (birth to present)

The birth process can traumatize a baby's spine and cause damage to the nerve system. Please indicate to the best of your recollection where and how you were birthed:

The information below will help us to see the types of PHYSICAL stresses that you have been subjected to and how they may relate to your present health status.

History of Chemical Stress

Chemical stresses occur during life due to any substance that is breathed, injected, ingested, or placed on the skin that is toxic to the body, (e.g.: food allergies, drug reactions, exposure to chemicals in the air, etc.) The following will give us insight into any exposures you may have had.

It is imperative that you list all medications as they may have an influence on your care.

History of Emotional Stress

It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if you have experienced any of the emotional stresses below:

Quality of Life

Expectations

As a result of my Chiropractic Care, I would like to:

FINANCIAL INFORMATION

Payment in full is expected on all FIRST VISIT services. All other fees are to be paid at time of service unless other arrangements have been made and agreed upon all writing.

Insurance coverage varies greatly. We cannot predict whether your policy will cover the services we provide in our office. We will contact your insurance company to determine if your insurance company covers Chiropractic Care. Please provide as much information as possible to help us determine your coverage

If this is an Auto Accident, please provide the following information

The information I have provided on this case history form, is true and accurate, to the best of my knowledge. I give Drs. Tiffany and Alex Leonida permission to render care to me today. This initial visit includes a health history/consultation, chiropractic exam/evaluation, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Enter the verification code in the box below.