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1818 Marron Road, Suite 103 Carlsbad, CA 92008
Patient Information
Cervical Curve Destruction
Health Hacks
Functional Resistance Stretching
Testimonials
Doctor’s Report
Traction
Nutritional Consult
Your First Visit
Advanced Healthcare Class
Menu
Patient Information
Cervical Curve Destruction
Health Hacks
Functional Resistance Stretching
Testimonials
Doctor’s Report
Traction
Nutritional Consult
Your First Visit
Advanced Healthcare Class
760-385-8352
Services
Holistic Services
Children’s Health
ADD
Allergies
Asthma
Autism
Colic
Ear Infections
Learning Disabilities
Chiropractic Care
Non-Toxic Makeup
Doctors
Corporate
Health Talk Topics
Why Invest
Events
Contact
Book an Appoinment
FRS with Dr Cordie
Menu
Services
Holistic Services
Children’s Health
ADD
Allergies
Asthma
Autism
Colic
Ear Infections
Learning Disabilities
Chiropractic Care
Non-Toxic Makeup
Doctors
Corporate
Health Talk Topics
Why Invest
Events
Contact
Book an Appoinment
FRS with Dr Cordie
Services
Holistic Services
Children’s Health
ADD
Allergies
Asthma
Autism
Colic
Ear Infections
Learning Disabilities
Chiropractic Care
Non-Toxic Makeup
Doctors
Corporate
Health Talk Topics
Why Invest
Events
Patient Information
Cervical Curve Destruction
Health Hacks
Functional Resistance Stretching
Testimonials
Doctor’s Report
Traction
Nutritional Consult
Your First Visit
Advanced Healthcare Class
Contact
Book an Appoinment
FRS with Dr Cordie
Menu
Services
Holistic Services
Children’s Health
ADD
Allergies
Asthma
Autism
Colic
Ear Infections
Learning Disabilities
Chiropractic Care
Non-Toxic Makeup
Doctors
Corporate
Health Talk Topics
Why Invest
Events
Patient Information
Cervical Curve Destruction
Health Hacks
Functional Resistance Stretching
Testimonials
Doctor’s Report
Traction
Nutritional Consult
Your First Visit
Advanced Healthcare Class
Contact
Book an Appoinment
FRS with Dr Cordie
Adult Intake Form
Adult Intake Form
1
Patient Info
2
Health Goals & Symptoms
3
Treatment History
4
Patient History
5
Agreement & Signature
Name
*
First
Last
Gender
*
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Hidden
Social Security Number
*
Primary Phone
*
Secondary Phone
Email
*
Best way and time to reach you
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
What are your health goals?
*
How do you expect to achieve them?
*
Please check off your chief concerns, if any, with your health:
*
Headaches/Migraines
Allergies
Chest/Rib Pain
Dizziness
Ear Aches
Asthma
Frequent Colds/Flu
Heartburn/Reflex
Low Energy/Fatigue
Weight Gain
Loss of Memory
Excess Gas/Bloating
Multiple Sclerosis
High Cholesterol
Bladder Problems
Digestive Problems
Neck Pain
Shoulder Pain
Arm Pain
Elbow Pain
Wrist Pain
Scoliosis
Low Back Pain
Mid Back Pain
Disc Problems
Insomnia
Ringing/Buzzing in Ears
High Blood Pressure
Low Blood Pressure
Fibromyalgia
Shortness of Breath
Cancer
Heat Condition
Kidney Disease
Hip Pain
Leg Pain
Knee Pain
Ankle Pain
Muscle Stress
Constipation
Hyperactivity
Arthritis
Depression
Bed Wetting
Menstrual Problems
Thyroid Trouble
Circulatory Problems
Nausea
Vascular Disorder
Immune System Disorder
Mood Swings
Chemical Stress
Physical Stress
Emotional Stress/Anxiety
Attention Disorders
Sciatica
Numbess/Tingling
Vertigo
Ulcers
Autoimmune Disease
Diabetes
Swollen Ankles
Skin Conditions/Acne
Diarrhea
Urinary Difficulty
Sinus Trouble
Osteoporosis
Which of these concerns (or elaborate here if not listed above) are your primary concern?
*
How long has this condition bothered you?
*
Is your pain sharp or dull?
*
Onset Speed
*
Sudden
Gradual
Associated with an event
Duration of condition/episode
*
Minutes
Hours
Days
Months
Years
Pattern of problem
*
Constant
Intermittent
Occasional
Cyclical
Initiating Factors
Aggravating Factors
Relieving Factors
Pressure on the spinal cord or nerves can be worse in the AM or the PM. Which is harder for you?
How does the problem affect your body and everyday activities?
Does this radiate to an extremity or stay in one area?
Are any of the above symptoms linked to a current car accident or workers compensation case?
Please use this space to include any other relevant details regarding the conditions cited above.
Have you been treated by a physician or practitioners for your condition or symptoms?
Yes
No
Name of Doctor
Date of most recent chiropractic visit
*
MM slash DD slash YYYY
What did you enjoy most and least about your previous chiropractic visits?
*
Have you undergone any other treatment for your condition or symptoms? Please elaborate if so.
*
Are you currently pregnant?
*
Yes
No
Do you have a history of cancer?
*
Yes
No
Check all that apply:
*
Smoker
Non-smoker
Drinks Alcohol
Does not drink alcohol
Takes drugs
Does not take drugs
List any known allergies (food, inhalants, etc.)
Please list any medications you are currently on
If there was a way we can help you come off these medications would you be interested?
Yes
No
Have you had any surgeries? If so when and for what?
Have you ever had any of the following diagnostic tests?
X-rays
MRI Scans
Bone Scan
CT scan
Myelogram
Disco gram
EMG
Occupation
*
Employer
*
Marital Status
*
Single
Married
Divorced/Separated
Widowed
Names and ages of children, if any
Education completed
High School
College
Post-Graduate
Family history
Heart disease
Stroke
Circulatory Disorder
Blood Pressure
Diabetes
How were you referred to us?
*
Consent
*
I agree that I have read the terms of our
Informed Consent
policy
Date
*
MM slash DD slash YYYY
Signature
*
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