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Adult Intake Form

Thank you for choosing ForeverYoung!

If you have booked an initial exam with us, please take the time to fill out this form the best you can prior to your appointment day. This helps to keep the clinic running smoothly and your appointment on time!

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HEALTH CARE PROVIDERS
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PATIENT SYMPTOMS
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How does your complaint impact your Quality of Life in the following areas?

Physical History & Stress / Trauma
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Postural Stress / Habits?
Current Level Of Exercise?
Type of exercise?
Chemical & Environmental Stress / Toxins
Rate your Current nutritional intake?
How many cups of water do you drink in a day?
Emotional Stress / Trauma
Current level of negaive stress?
How do you cope with negative stress?
Rate yor current energy level:
What is your ideal sleep position?
How much sleep do you get per night?
Family history of?
Women's Health History / Trauma
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Chiropractic Goals
What do you expect from your chiropractic care?
What is your greatest motivation for care in our office?
Family Concerns

Thanks for submitting! We have received it.

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