Atlanta Chiropractor

   Please provide the following contact information:

Name
Age
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
Occupation

Check any of the following symptoms you have experienced in the past 6 months.

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels or effects you when it is at its worst.

Does this cause you to be:
Moody
Irritable
Interrupt Sleep
Restricted on Daily Activities

Does this affect your work:
Decision Making
Poor Attitude
Decreased Productivity
Exhausted at End of Day
Unable to Work Long Hours

Does this affect your life:
Lose Patience with Spouse or Children
Restricted Household Duties
Hinders Ability to Exercise or Participate in Sports
Interferes with Ability to Participate in Hobbies or
Other Desired Activities

I would like to come to the Doctor's office for a complete evaluation. There is NO CHARGE for this examination. This will allow me to find out if I can be helped by Chiropractic without any financial barriers.
         Yes No

I would like to come to a class on Stress and Wellness.
Yes No

I would like the Doctor to call me to discuss my health problems before making an appointment.
Yes No

Are you a member of an HMO or Health Care Network?
Name of HMO