Chiropractic Intake Form for Vital Shift

Are you presently working?

Full Time

Part Time

Retired

Caregiver

Student

Presently not working

Other

Please tell us how you prefer to be contacted to confirm appointments

Call

Text

Other

Kindly provide the location address of the appointment, if different from the primary residence.

Which option best fits your address?

Single family home

Townhome/Duplex

Condo/Apartment

Other

Please provide any special instructions for our doctor to find your location. (Gate access code, parking, directions, etc.)

Please list any heath care professionals you have seen in the past?

Characters: 0/255

Females Only, if you are pregnant, how many weeks are you pregnant?

Characters: 0/255

Please describe any past of recent injuries in the past 3 months.

Please describe any past of recent injuries in the past 6 months.

Some health problems are hereditary. Please describe any health issues your parents or siblings are experiencing (or have experienced).

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