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New Patient Information Intake Form 2

Family History

Marital Status:
S
M
D
W
M | F
M
F
M | F
M
F
M | F
M
F
M | F
M
F

Any family history of series illnesses (circle those which apply)

Father
Cancer
Diabetes
Heart
Other
Mother
Cancer
Diabetes
Heart
Other
Sister
Cancer
Diabetes
Heart
Other
Brother
Cancer
Diabetes
Heart
Other
Other
Cancer
Diabetes
Heart
Other

Social History

Do you exercise?
Yes
No
Do you stretch or do yoga?
Yes
No
Do you eat a healthy diet?
Yes
No
Do you drink alcohol?
Yes
No
Drink soda, including diet soda?
Yes
No
Do you currently smoke tobacco of any kind?
Yes
Not Any More
Never Been
If yes, how interested are you with continuing to smoke?
Not Interested
0
1
2
3
4
5
6
7
8
9
10
Very Interested

For Insurance Chiropractic Treatment

(Give care to receptionist to make a copy)

AUTHORIZE & RELEASE: I authorize payment of insurance BENEFITS DIRECTLY TO Natural health. I authorize Natural

Health to release all information necessary to communicate with personal physicians and other healthcare providers and payors and

to secure the payments of benefits. I understand that I am responsible for all cost of chiropractic care regardless of insurance

coverage. I also understand that if I suspend or terminate my schedule of care as determined by the Doctors, any fees for


professional services will be immediately due and payable.

PATIENT SIGNATURE




GUARDIAN’S SIGNATURE




Signatures to be filled in our office*

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