Chiropractic New Patient Form

New chiropractic patient paperwork
  • Date Format: MM slash DD slash YYYY
  • Medical History

    The following members have a same or similar problem as I do:
  • When was your last period?
  • Are you pregnant?
  • Most patients that see a chiropractor have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care).
  • Area of Complaint(s)

    Please answer the questions below about your current area(s) of complaint to provide Dr. Sauvage with more information
  • Please describe your area(s) of discomfort
  • Date Format: MM slash DD slash YYYY
  • For example: sitting, driving, lying down, lifting, squatting, chores.....
  • For example rest, ice, heat, stretching lying down, sitting, standing, medication....
  • This field is for validation purposes and should be left unchanged.