To shorten the time you spend on your first, please print out and complete this form.  Bring it along on your first visit.

Welcome, we are truly pleased that you are seeking chiropractic care and that you are considering us for your family chiropractor.  We hope that our relationship is a long and pleasant one.

General Information:                                             

Name________________________________________________________   Date _______________________

Address _________________________________________________ City ______________________________

State ______ Zip _______

E-mail (please print clearly) Note: we will not give it out _____________________________________________

Phone number _____________________________________  Mobile _________________________________

Date of Birth ____/____/___________ Referred by _______________________________________________

Health Information:                                             
Please answer each question.  We will discuss this so don’t worry if you there are any that you are unsure how to answer, just fill in a short response.

For which of these reasons are you seeking chiropractic care?  (Please check one)
____ health maintenance         or     ____ because of a particular problem ______________________________

_________________________________________________________________________________________ 

Occupation ___________________________________________________

Marital status __________________  Number of children _____________________

When (approximately) was your last chiropractic adjustment?  ______________________________________________________________________________

Name of your previous doctor of chiropractic ____________________________________________________________________________________________

(females) Do you have any reason to believe you might be pregnant?___________________

Date (approximately) of last x-rays ______________  Type of x-ray (medical, dental, chiropractic)?____________________

Contributory Destructive Information:

Have you ever been subjected to radiation therapy?______________________________ 

Past Prolonged medications (please list all drugs that you have ever taken over a prolonged period of time)___________________________________________________

Present medications (drugs that you use regularly or occasionally, even non-prescribed substances like aspirin)________________________________________

Surgery (please list all surgery you have had)___________________________________________________________________________________________

Serious Illnesses (please list any you have had) _________________________________________________________________________________________

Accidents or injuries ____________________________________________________________

Fractures _____________________________________

Medical care (if you are currently under medical care please list your doctor's diagnosis and the treatment you are receiving ___________________________________________   

What to expect… 

We are committed to offering you the finest in precise, gentle and effective chiropractic care.  Your chiropractor is an experienced practitioner and educator, and has served in a number of leadership roles in the chiropractic profession.  Dr. Brown lectures both in the United States and internationally and has been involved in the growth of the chiropractic profession.  His commitment to quality and integrity has resulted in a distinct approach to practice.
There are several unique things about our practice that you will want to know about. 
1. We use an open approach.  The family adjusting suite has no closed doors and all family members are welcome to be present.  Any practice member may request a closed door to discuss private matters.  Just let us know and we will be happy to move to the consultation room to visit with you.
2. We use safe, state-of-the art thermographic (skin temperature) pattern analysis to help us know when a vertebral subluxation is present.  This computerized instrument measures and records skin temperature variations.
3. Not all practice members need x-rays.  If needed they are taken with precision equipment here on the premises.
4. No insurance needed or required.  We are committed to making the finest quality care affordable.  The doctor will complete your spinal analysis and make recommendations for your care based upon your actual needs.  This will include a discussion about financial arrangements.