Date: ___________________
Name: _________________________________________________
Address: _______________________________________________
City: _____________________ State: _____ Zip ______________
Phone #'s:    Home: ___________________________
                  Cell:    ___________________________
                  Work:  ___________________________
Age: _____ DOB: ______________________  Gender ________
Marital status:  S  M  W             Number of children  ________
Occupation: ____________________________________________
E-mail address: _________________________________________
Will we be filing your insurance? _____
Referred By: ____________________________________________
Primary reason for consulting our office: _____________________
_______________________________________________________
_______________________________________________________
Any other associated warning signs or complaints?  ____________
_______________________________________________________
How long has this been going on? _____  days weeks months years
Has this ever occurred before? _____
Have you seen other chiropractors? _____
If so, who? _____________________________________________
Name of your medical doctor: ______________________________
Others seen for this condition: _____________________________
Describe your symptoms:  sharp, dull, numb, weak, travels, constant
What makes your symptoms worse? _________________________
_______________________________________________________
What makes your symptoms better? _________________________
_______________________________________________________
Do your symptoms cause you to: (circle each that apply)
lose sleep - be short tempered - miss work - miss play - lose focus -
be less productive
Using the diagrams, indicate the location of your symptoms.

 

 

 

 

Are there any other facts about your current problem? __________
________________________________________________________
________________________________________________________
________________________________________________________

 

INTAKE FORM                  Nature's Way Chiropractic

Injury History

Birth ___________________________________________________
Broken Bones ____________________________________________
Sports __________________________________________________
Knocked Out? ____________________________________________
Car Accidents ____________________________________________
Medications ______________________________________________

The statements made on these forms are accurate to the best of my
recollection.

Signature: __________________________  Date: ________________

AGREEMENTS

Office fees 1st visit/exam $65.00 Regular office visit $35.00
X-ray fees -range from $54.00 to $100.00
(depending on the number taken)

Informed consent to chiropractic care.
I hereby request and consent to the performance of chiropractic adjustments, other chiropractic procedures and if necessary diagnostic x-rays on me by doctor Eric Moore and/or anyone authorized by him. I further understand and am informed that, as in all health care, there are some slight risks to treatment and do not expect the doctor to be able to anticipate or explain all risks and combinations; and wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the
facts then known are in my best interest. I have read this consent and intend this consent form to cover the entire course of my care for this condition and any care in the future.

Eric Moore, D.C.
dba Nature's Way Chiropractic
137 Hughes Road
Madison, AL 35758
256-464-0522  office
256-464-0544  fax