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New Patient 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!

Postural Stress / Habits?
Current Level Of Exercise?
Type of exercise?
Rate your Current nutritional intake?
Current level of negaive stress?
How many cups of water do you drink in a day?
How do you cope with negative stress?
Rate yor current energy level:
What is your ideal sleep position?
What do you expect from your chiropractic care?
How much sleep do you get per night?
Family history of?
What is your greatest motivation for care in our office?
Your child(rens) birth was:
If vaginal with interventions (check all that apply)

Thanks for submitting! We have received it.

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