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New Patient Paperwork

New Patients please fill out the form below

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Have you been adjusted by a chiropractor before?

The symptom(s) that have prompted me to seek care today include: 

Are the result of:
An Interest In:
Quality of Symptoms

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Aggravating or relieving factors ( What makes it better or worse, such as time of day, movements, certain activities, etc)

Prior Interventions (What have you done to relieve the symptoms)

How does your current condition interfere with your:

Review of Systems

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please check the box beside any condition you've Had or Have.

Musculoskeletal

Neurological

Cardiovascular

Respiratory

Digestive

Sensory

Skin

Endocrine

Genitourinary 

Constitutional 

Past Personal, Family and Social History

Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully. 

Illnesses 

Check the illnesses you Had in the past or Have now.

Operations

Surgical interventions, which may or may not have included hospitalization.

Operations

Treatments

Check the ones you've received in the Past or are receiving Currently.

Injuries

Family History

Some health issues are hereditary. Tell us about the health of your immediate family members 

Social History

Tell us about your health habits and stress levels.

Activities of Daily Living

How does this condition currently interfere with your life and ability to function?

Personal health goals:

On a scale of 1 to 10 with 1=Poor and 10=Excellent, please rate how well you think you are doing in the following categories:

Do you take?

Acknowledgments 

I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.

I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.

I realize that an X-ray examination may be hazardous to an unborn child and certify that to the best of my knowledge I am not pregnant.

I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.

I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.


To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.

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


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Contact Us

Our Location

Federal Way, WA Chiropractor

Hours of Operation

Monday

1:30 pm - 7:30 pm

Tuesday

8:30 am - 2:30 pm

Wednesday

1:30 pm - 7:00 pm

Thursday

8:30 am - 2:30 pm

Friday

Closed

Saturday

Closed

Sunday

Closed

Monday
1:30 pm - 7:30 pm
Tuesday
8:30 am - 2:30 pm
Wednesday
1:30 pm - 7:00 pm
Thursday
8:30 am - 2:30 pm
Friday
Closed
Saturday
Closed
Sunday
Closed