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Patient Data

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Contact Information

Reason For Seeking Chiropractic Care

Previous Chiropractic Care

If you have been under chiropractic care in the past...

For Women

The information below will help us to see the types of PHYSICAL, EMOTIONAL and CHEMICAL stresses you have been subjected to and how they may relate to your current health status.


The minor, often ignored repetitive physical traumas that we endure on a daily basis are too numerous to list. Please discuss the major traumas that you remember from your childhood up to the present.

Have You Ever:


Chemical stress occurs when a substance that is toxic to the body is breathed, injected, taken by mouth or placed on the skin (Eg. food allergies, drug reactions, exposure to chemicals in the air or on skin, etc.) The following will reveal exposures you may have had.


Emotional stress is detrimental to our health. It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate which of the following you are experiencing or have experienced.

Quality of Life


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Office Hours

Monday7:30 - 12:002:00 - 6:00
TuesdayClosed2:00 - 5:30
Wednesday7:30 - 12:002:00 - 6:00
Thursday7:30 - 12:002:00 - 6:00
FridayBy Appt.Closed
SaturdayBy Appt.Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:30 - 12:00 Closed 7:30 - 12:00 7:30 - 12:00 By Appt. By Appt. Closed
2:00 - 6:00 2:00 - 5:30 2:00 - 6:00 2:00 - 6:00 Closed Closed Closed

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