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CONFIDENTIAL PATIENT INFORMATION

PATIENT INFORMATION

If nature of injury is an auto accident, please provide auto insurance information below. Otherwise please skip to REASON FOR VISIT

REASON FOR VISIT

If you have no symptoms or complaints and are here for 'Chiropractic Wellness' Services, please skip to the 'GENERAL HEALTH HISTORY'

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PAST HEALTH HISTORY

GENERAL HEALTH HISTORY

Because accumulation of stress affects your overall health and ability to heal, please pay close attention in answering these questions below as it will help us help you better!

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