Welcome to the Spinal Corrective New Patient Center!

We understand that arriving at a doctor's office for the first time can be nerve racking. If you've never experienced chiropractic care before, you may not know what to expect when you come to our Cedar Rapids chiropractic office for the first time. Filling out paperwork, learning new faces and names, and getting to know your way around the office can be an overwhelming experience. That's why at Spinal Corrective Center, P.C. our aim is to remove any unnecessary stress or tension and make you feel comfortable during your visit.

As a new patient your next step is to fill out the required health history form below prior to your first visit. This lets us know the history and current state of your health. What questions, concerns, or goals regarding wellness, can we help you with?


Spinal Corrective Center, P.C. offers our patient form(s) online so they can be completed in the convenience of your own home or office. You can fill out the required new patient form in one of two ways listed below:

OR

Fill out the Online Form below and Click Submit.

To Download and Print:

  • If you do not already have AdobeReader® installed on your computer, click here to download.

  • Download the form, print and fill in the required information.

  • Bring in your printed and completed form with you to your appointment.

 

Instructions for online form:

  • Scroll down and fill out all the required fields.

  • Click Submit.

  • Once we receive the completed form we will contact you via phone to setup a consultation or appointment.

If you should have any questions regarding the New Patient Health History form please call our office at 319.393.3996.

 

New Patient Health History - Online Form

 
 
 
Patient Information
Name: *
Name:
Sex: *
Home Number: *
Home Number:
Cell Phone Number: *
Cell Phone Number:
Work Number:
Work Number:
Birthday: *
Birthday:
Married/Civil Union: *
Spouse Name:
Spouse Name:
Address: *
Address:
Employer Information
Employed:
History
If multiple nutrition supplements/medications, please bring list. (name, amounts, frequency, length of use, reason for use)
(name, amounts, frequency, length of use, reason for use)
Health Checklist
Health Checklist
Social History and Life Choices
Alcohol:
Diet Food Products:
OTC Stimulants:
Homemade Food:
Soft Drinks:
Water:
Caffinee Drinks:
Drugs:
Exercise:
Processed Food:
Tobacco:
Chiropractic Experience
How Did You Find Our Office? *
Have You Been To A Chiropractor Before?
Date of Last Visit
Date of Last Visit
Has Any Member Of Your Family Ever Seen A Wellness Chiropractor?
Reason For The Visit
Has This Concern?
Does This Concern Interfere With:
Has This Concern Occured Before?
Have You Seen Other Doctors/Therapists For This Concern?
Results: