Full Name

Age

Date of birth

Address

City

Postal code

Phone

Cell Phone

Occupation

Employer

Marital Status

How did you hear about us? Who may we thank for referring you?

HEALTH CARE PRACTICIONER HISTORY

Current Primary Care Physician

Physician Location

Have you ever received chiropractic care?

Yes

Name of D.C.

Last visit to this chiropractor:

Reason for Leaving:

REASONS FOR SEEKING CHIROPRACTIC CARE

What concerns do you feel Lakeville Chiropractic can address for you?

For Women

Are you pregnant?

Yes

If x-rays are recommended your signature is required (below) to indicate that you are not pregnant.

Clear

Signed on this Date

If pregnant, Due Date

OBGYN or Midwife

ADULT CONSULTATION HISTORY

Main complaint (if no complaint just write “Wellness”)

Any other complaints

How long have you suffered with this problem?

Do you know how this problem began?

What have you tried to do to get rid of this problem that DID NOT work?

Have you become discouraged about handling this problem?

When your problem is at its worst, how does it make you feel?

How does the problem interfere with the following areas of your life?

Work

Family

Hobbies

Life

Does this problem cause stress for you?

What do you do that makes this problem worse

What gives you some temporary relief?

How much older does this make you feel?

What is the effect it has on your body functions? (0 - no pain 10 - worst pain)

PLEASE READ AND SIGN BELOW

The information I have provided on this form, is true and accurate to the best of my knowledge. I give Dr. Michael P. Griffin permission to render care to me today. This initial visit includes a health history/consultation, chiropractic exam/evaluation. I also give my consent to have the doctor order any x-rays that he deems appropriate, and any initial care that is determined to be clinically necessary and mutually agreed upon.

Signature

Clear

Today’s Date

Signature of Parent (for minor):

Clear

Today’s Date

Mission Statement

“The families in our community have lost control over their greatest asset; their health. They are sick, suffering, and drowning in chemicals.

We exist to adjust your spine and your mind, while illuminating a new vision that harnesses your innate health potential.

Become empowered, challenge the status quo, reclaim control, and have the audacity to suggest that you were born to be healthy.”

-Michael P Griffin, DC