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  • CONFIDENTIAL HEALTH INFORMATION

  • Please allow our staff to photocopy your driver's license and insurance details. All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.

    Shelly Jones, D.C. Chiropractic Wellness Center 5209 Forest Drive, Suite C Columbia, SC 29206 803-771-9990 www.drshellyjones.con doc@drshellyjones.com

  • Demographic Information

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  • Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply.

  • Primary Complaint

  • Secondary Complaint

  • Additional Complaint

  • How does your current condition interfere with your:

  • Review of Systems

    Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select any condtion that you've had or currently have.

  • Health History

    Please identify your past health history, including accidents, injuries, illnesses, and treatments. Please complete each section fully.

  • Illnesses

  • Allergies

  • Operations

  • Treatments

  • Injuries

  • Family History

    Some health issues are hereditary. Tell Dr. Jones about the health of your immediate family members.

  • Mother

  • Father

  • Sister 1

  • Sister 2

  • Brother 1

  • Brother 2

  • Additional Entry

  • Social History

    Tell Dr. Jones about your health habits and stress levels.

  • Activities of Daily Living

    How does this condition currently interfere with your life and ability to function?

  • Acknledgements

    To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

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