• CONFIDENTIAL HEALTH INFORMATION

    Please allow our staff to photocopy your driver’s license and insurance details.
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  • History of Chief Complaint(s)

  • 9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

  • 12. Activities of Daily Living

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  • Review of Systems

  • Chiropractic focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select beside any condition that you’ve Had or currently Have.
    *If Any section does not apply to you, check "None" - Do not leave any sections blank.

  • a. Musculoskeletal

  • b. Neurological

  • c. Cardiovascular

  • d. Respiratory

  • e. Digestive

  • f. Sensory

  • g. Skin

  • h. Endocrine

  • i. Genitourinary

  • j. Constitutional

  • Past Personal, Family and Social History

    List your past health history, including accidents, injuries, illnesses andtreatments
  • 18. Illnesses

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  • 19. Operations

  • 20. Treatments

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  • 21. Injuries

  • 22. Family History

    Some health issues are hereditary. Tell Dr. Bowman about the health of your immediate family members.
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  • 24. Social History

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  • Acknowledgements

    To set clear expectations, improve communications and help you get the best results, please read each statement and initial your agreement.
  •   I instruct the Chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.
      I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.
      I realize the X-ray examination may be hazardous to an unborn child and I certify that to the
    best of my knowledge I am not pregnant. Date of last menstrual period   Pick a Date   .
      I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
      I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I received.
       To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.

  • Clear
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  • Medications and Supplements

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  • Clear
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  • Neck Index

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  • This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem

  • Back Index

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  • This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

  • Should be Empty: