Confidential Patient Information

This information is confidential. If we do not sincerely believe that your problem will respond favorably we will not be able to accept your case. We will refer you to disciplines we feel will help you. In order for us to understand your health problems properly, please complete this form neatly, accurately and completely. THANK YOU

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DOCTORS CONSULTED FOR THIS CONDITION:

FINANCIAL INFORMATION:

WHAT SURGERIES HAVE YOU HAD?

LIST FORMER SERIOUS ACCIDENTS AND FALLS: (AUTO, WORK, HOME, LEISURE, SPORTS, OTHER)

LIST BROKEN BONES:

LIST MEDICATIONS AND/OR DIET SUPPLEMENTS YOU TAKE:

LIST ANY DISEASE OR ILLNESS WITH WHICH YOU HAVE BEEN DIAGNOSED:

WORK/LEISURE ACTIVITIES

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