Patient Paperwork

 
 

HEALTH HISTORY

OUTLINE OF PROCEDURES OF CARE

Step One:

All new patients are requested to fill out this personal health history questionnaire completely as possible.

Step Two:

Please read and sign all other forms.

Step Three:

A one-on-one consultation with the doctor will be done to discuss your health issues and goals, uncover the

layers of past damage done and to help determine what may be the cause.

Step Four:

A comprehensive examination and evaluation including those tests necessary will be performed to further

help determine the precise cause of your problem.

Step Five:

The doctor will advise you if additional laboratory tests or x-rays are needed.

Step Six:

You will be asked to schedule a follow-up appointment called the “Report of Findings / Patient’s Action Steps”

at which time the cause of your current condition will be discussed. After reviewing your case, the doctor will

decide if you will be accepted as a patient and a thorough explanation of care recommendations and the

action steps you need to take to obtain the results you desire.

Step Seven:

Initiate care and start on your path to creating your optimum inner health and wellness.

Congratulations on taking the first steps to creating true wellness from within.

Name *
Name
Phone Number
Phone Number
Date of Birth
Date of Birth
Business Phone
Business Phone
Phone Number for Emergency Contact
Phone Number for Emergency Contact
Name of Insurance Company
Past History of Sickness / Loss of Wellness
Below is a list of diseases / conditions, which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of chiropractic care.
Check any of the following diseases you have or had:
Immune System
Gastro-Intestinal
Nervous System
Genito-Urinary
Cardio-Respiratory
Eyes, Ears, Nose & Throat
Female
Male
Exercise
Sleep
Work
I would like to:
Energy, Vitality
Body Composition
Stress: Mental and Emotional
Life Enrichment
Family History
The following members have same or similar problems as I do:

DiSiena and Irvine Chiropractic and Wellness

6 Venture Suite 115, Irvine, CA 92618 

949-559-6030