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Welcome to our office!


Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 




About this Patient 

Male
Female
Other
Married
Single

About the Spouse 

Employer Information

Authorization of Care

• I authorize the doctor or his staff to render care as deemed appropriate for me and / or my child.

• I authorize Momentum Health Chiropractic to release and / or request records to or from other providers as may be necessary.

• I understand I am responsible for all bills incurred in this office.

• I authorize assignment of my insurance benefits (if applicable) directly to the provider.

• I understand that after any initial promotional services all care is rendered at usual and customary fees.

Cash
Check
Credit Card
Car/Work Insurance

Reason For Seeking Care

Present Complaints

Dull
Sharp
Ache
Numb/Tingle
Stabbing
Constant
Occasional
Staying the Same
Getting Worse
Mild
Moderate
Severe
Worse in the morning
Worse in the evening
Pain radiates elsewhere
Dull
Sharp
Ache
Numb/Tingle
Stabbing
Constant
Occasional
Staying the Same
Getting Worse
Mild
Moderate
Severe
Worse in the morning
Worse in the evening
Paid radiates elsewhere
Dull
Sharp
Ache
Numb/Tingle
Stabbing
Constant
Occasional
Staying the same
Getting worse
Mild
Moderate
Severe
Worse in the morning
Worse in the evening
Pain radiates elsewhere
Dull
Sharp
Ache
Numb/Tingle
Stabbing
Constant
Occasional
Staying the same
Getting worse
Mild
Moderate
Severe
Worse in the morning
Worse in the evening
Pain radiates elsewhere
Sleep
Work
Daily Routine
Sitting
Driving

Please mark all areas of concern on the image below:

General Health History


Headaches
Migraines
Shortness of Breath
Allergies/Asthma
Medication Side Effects
Diabetes
Hands or Feet cold
Muscle Aches
Trouble Walking
Leg/Foot Numbness
Fainting
Gall Bladder Trouble
Ringing in Ears
Ear Problems
Sleeping Problems
Vision Problems
Thyroid Problems
Liver Disease
Kidney Problems
Light Bothers Eyes
Urinary Problems
Easy Bruising
Tobacco Use
Dental Problems
Fibromyalgia
Blood Thinner Use
HIV Positive
Cancer
Depression
Alcohol Use
High Blood Pressure
Low Blood Pressure
Stroke History
High Cholesterol
TMJ
Digestive Problems
Pain all Over
Tension/Irritability
Chest Pains
Heart Pacemaker
Heart Problems
Other
Headaches
Migraines
Shortness of Breath
Allergies/Asthma
Medication Side Effects
Diabetes
Hands or Feet cold
Muscle Aches
Trouble Walking
Leg/Foot Numbness
Fainting
Gall Bladder Trouble
Ringing in Ears
Ear Problems
Sleeping Problems
Vision Problems
Thyroid Problems
Liver Disease
Kidney Problems
Light Bothers Eyes
Urinary Problems
Easy Bruising
Tobacco Use
Dental Problems
Fibromyalgia
Blood Thinner Use
HIV Positive
Cancer
Depression
Alcohol Use
High Blood Pressure
Low Blood Pressure
Stroke History
High Cholesterol
TMJ
Digestive Problems
Pain All Over
Tension/Irritability
Chest Pains
Heart Pacemaker
Heart Problems

Past History

Family History

Heart Disease
Cancer
Diabetes
Heavy Medication Use
Arthritis
Other
Heart Disease
Cancer
Diabetes
Heavy Medication Use
Arthritis
Other

Thank you for taking the time to fill out this form.

Contact Us

We look forward to hearing from you

Office Hours

Monday

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Tuesday

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Wednesday

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

Saturday

Closed

Sunday

Closed

Monday
9:00 am - 12:00 pm 3:00 pm - 6:00 pm
Tuesday
9:00 am - 12:00 pm 3:00 pm - 6:00 pm
Wednesday
9:00 am - 12:00 pm 3:00 pm - 6:00 pm
Thursday
9:00 am - 12:00 pm 3:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm
Saturday
Closed
Sunday
Closed

Location

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