About You Form

ABOUT YOU

Gender*
Please select one option
Marital Status*
Please select one option

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

Do you have insurance?

REFERRAL INFORMATION

Are you working with an attorney?
How did you hear about us?
What type of accident caused your injury?*
Please select one option
Are there any additional symptoms which have appeared since the accident occurred?
How have your symptoms changed since the accident?

CURRENT HEALTH

Other than the information already provided, do you have additional health concerns involving any of the following?

REASON FOR VISIT

How long have you had this complaint?*
Please select one option

On the body diagram, please indicate your areas of symptoms by drawing in the appropriate symbols.

P - Pain N- Numbness W - Weakness S - Shooting A- Aching
On a scale 1 to 10, how do you rate your discomfort?
How often do you feel this discomfort?
How has this complaint changed since the onset?
What type of accident caused your injury?
Were you wearing a seatbelt?
Did the airbag deploy?
Did you come into contact with anything at the time of the collision?
Did you receive an injury to the head?
Did you lose consciousness?
Did police arrive at the scene?
Was an accident report taken?
Patient vehicle impact?*
Please select one option
Was your vehicle or cycle towed from the the scene?
Did Emergency Medical Services arrive at the scene?
Are there any additional symptoms which have appeared since the accident occurred?
How have your symptoms changed since the accident?

PERSONAL AND FAMILY HISTORY

WORK SOCIAL HABITS

Current work habits? Choose all that apply*
Please select at least one option
Current social habits? Choose all that apply
Current exercise habits? Choose all that apply
Diet and nutrition habits? Choose all that apply

WOMEN'S HEALTH

When was your last PAP/pelvic exam?
When was you last mammogram?
What was the date of your last menstrual period?

INFORMED CONSENT TO TREAT

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and Its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, ro adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I"m responsible for timely payment of such services. I understand and agree that health/accident insurance policies are na arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Thank you for taking the time to fill out this form.

Office Hours

Walker Chiropractic and Wellness Center

Monday  

9:30 am - 1:00 pm

3:00 pm - 7:00 pm

Tuesday  

3:00 pm - 7:00 pm

Wednesday  

9:30 am - 1:00 pm

3:00 pm - 7:00 pm

Thursday  

9:30 am - 1:00 pm

3:00 pm - 7:00 pm

Friday  

9:30 am - 1:00 pm

Saturday  

Closed

Sunday  

Closed

Location

Find us on the map