Please provide the following contact information:                                                                                                                                                                                              

Patient's Name                                                   Today's Date       

Home Phone      Cell Phone #     Work Phone       

 Permanent Address   Apt #         City     

 State/Prov    Zip/Postal Code/Country       E-mail Address     NOTE: Legault Chiropractic does NOT sell nor share your e-mail address with Any outside parties, except as You request. We may send you an E-Newsletter once a month &/or a notice of  any "Specials of the Month" as they may interest you.     

  Gender   . Male Female       Marital Status  . Single Married Civil Partner Widowed Separated Divorced      Date of Birth     Occupation    RETIRED

Place of Employment      Social Security #        Name of Spouse 

        Insurance Company                    

 Name of Children & Age

WHOM may we be Thank for Referring You to our office?                

Have you EVER had Chiropractic Care in the Past ?       . Yes No     If "YES" Please indicate When?

Name of your prior Chiropractor     Where?   and Why did you stop?

Was it a Great experience?    . Yes No      Did they take Spinal X-rays?   Yes . No I can not recall       Approx date of Last Spinal X-rays

 What is you reason for seeking Chiropractic care

I have no complaints.  I am here for a wellness check up.     

I am seeking Chiropractic care for the following -     

Is this related to: Personal Health Problem(s) Work Accident    Auto Accident  School/Sports Injury    

Other  	

SUBLUXATIONS (spinal misalignments) interfere with the communication from your brain to your body. When these interferences are advanced, an alarm system occasionally signals for help by sending signs or symptoms such as pain, numbness &/or health problems to let you know that there is a problem. Please let us know where the alarm system is sounding on you?

Neck Pain          		Headaches           		Shoulder/Arm/Hand Pain      	Allergies                 
Mid Back Pain       		Dizziness             		Hip/Leg/foot Pain           	Sinus Problems            
Low Back Pain       		Nervousness           		Digestive Problems          	Loss of Sleep             
Constipation        		Numbness/Tingling     		Difficulty Breathing        	Urinary Problems               
Other   

(Females only: Are You Pregnant?   
NO
YES
 	 	Do you/Did you have Menstrual Problems  
NO
YES
  		Signs of Menopause  
NO
YES
 )           

              When did these signs or symptoms that brought you here 1st  appear?    Are these signs or symptoms: . Constant Frequent Occasional Intermittent  

 A Subluxation irritates nerves with various sensations. Is yours?  (Select Any /All of the following options that apply):

            Sharp     Burning         Throbbing        Stabbing        Dull    Achy    

SOCIAL HABITS: Do you   Exercise daily     Eat a healthy diet    

                                  Water Consumption . 1 or Less 2 3 4 5 6 7 8 9 10 + # of glasses per day     Tobacco/Smoke . None Less than 1 1 2 3 4 5 6 + # packs per day                 

                                                         Alcohol Consumption . Never/None Occasionally Socially Daily      Drug Consumption  . Never/None Occasionally Socially Daily

PAST HISTORY: Have you EVER had any SURGERY: Select any/ALL of the following options that apply:

Tonsils   Appendix   Gall Bladder    Heart     Cancer     Spinal Surgery                                         
  Other    	 I have NEVER had Any Surgeries

	(Females Only:Caesarian  Hysterectomy Other  

Please LIST ALL MEDICATIONS for ANY Health Problem(s)    

REVIEW OF BODY SYSTEMS: (Examples Only, Your Problem(s) may be Different) Please “CHECK OFF Any/ALL System which gives you a problem or for which you are taking medications.

HEART/CIRCULATION (Bld. Pressure)                 LUNGS/RESPIRATORY (Asthma)          GASTROINTESTINAL (Heartburn/Constip./Diarrhea) 		          

BLOOD/LYMPHATIC (Leukemia/HIV Pos.)             NEUROLOGICAL (Numbness/paralysis)    ENDOCRINE/HORMONES (Diabetes/Thyroid/Female Hormones)             

 EYES (Glasses/Glaucoma/ Other)           	  	IMMUNE SYSTEM (Freq. Colds/Fever)     SKIN (Rashes/Pimples/Skin Cancer)   

EARS/NOSE/THROAT/MOUTH                      	GENITO/URINARY (Reproductive/Bladder) PSYCHIATRIC (Depression / Extreme Stress)               

RESPONSIBILITY:

PERSON/ENTITY RESPONSIBLE FOR THIS ACCOUNT:             SELF SELF + SPOUSE / GUARDIAN SELF + INSURANCE  

NOTE: It is the Patient's Responsibility to Notify the Legault Chiropractic Health Center Who is Liable for Charges incurred &/or to be incurred in this Office & Re-Notify Immediately if their "Care Liability" CHANGES while under care. [ex. from-to: Personal / Auto Accident / Workers' Comp / Other]

PRIVACY STATEMENT: We, at the Legault Chiropractic Health Center , honor and respect all of our patients & their right to privacy. It is the regular policy of this office to minimize disclosure or dissemination of any personal information on any/all of our patients. Neither your name, address, phone number(s) nor health/financial record will be used, nor shared with any outside agent, except as expressed & authorized by you (example – your spouse &/or Insurance Company) or as Required by Law.

FEES ARE DUE WHEN SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE.

 [A copy of your driver’s license is mandatory if payments are to be Other than CASH.]

I hereby authorize the Legault Chiropractic Health Center to disclose my private health and financial information to &/or   (ex: Name your Spouse/Parent/Adult-Child /Insurance Company) for the purpose of payment, coordination of my care &/or to transport said information for me in my absence.

Signature of Patient     Date  mm/dd/yy   

          Patient's Authorization for Care

 To PRINT   Click 'CTRL' + 'P' at same time

Please NOTE: At this time, this form can NOT be Transmitted Electronically. Therefore, PLEASE PRINT this FORM,   SIGN it where indicated, & BRING IT with YOU when you COME IN for your SCHEDULED APPOINTMENT.

Being in PAIN is Not Fun! Help Us to Help Others!  Don't wait!  Tell your Family & Friends about this Website. 

You may be the one who Saves them from a Great Deal of Pain/Suffering or maybe even SAVES their LIFE ! 

What a GREAT FEELING that can be for YOU!