Adult Initial Assessment Form

Dear New Patient, It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable. To help us serve you better, please complete the following information. We look forward to working with you to build better health for your family. *

I agree with submitting the form below via email

Please select the option above if you would like to submit this online form directly to Dr. Muller's email address. If you prefer to download a PDF version of this form, please click here to download a copy. Complete the form and bring a printed version with you on your initial appointment.

IMPORTANT: We will use the minimum necessary amount of protected health information in any communication and will not send you unnecessary emails and/or TXT messages. By providing your consent below, we will be able to send you reminders for upcoming appointments, receipts and occasional notifications. *

I consent to receiving appointment reminders, receipts, and occasional notifications via email and/or TXT messages. I understand I can withdraw my consent at any time.

My Email Address is *

Patient Full Name *

Date of Birth *

Age *

Address *

Home Phone # *

Mobile Phone #

Business Phone #

Occupation

Marital Status *

Children? *

Employer's Name

Name of Spouse/Partner (if applicable)

How Many Children? (if applicable)

Have you ever been treated by a chiropractor? *

How long have you seen a chiropractor for? (if applicable)

Name(s) of previous chiropractor(s) (if applicable)

When was your last chiropractic appointment? (if applicable)

Reason for last chiropractic visit (if applicable)

Name of Family Doctor *

Who may we thank for referring you to our office?

YOUR HEALTH PROFILE

What health concerns do you feel we can address for you? *

When did this episode start?

Since this began, is it worse, better or about the same?

What makes it better?

Have you had this before and when?

What makes it worse?

If you selected Other, please add more details

Other doctors seen for this condition?

If you answer YES, please specify below

Doctor's Name

Date (approximately)

Diagnosis

Level of stress in your life (1-10)

Is your health better, worse or the same as 5 years ago?

Explain why you think this is

Have you ever had any fractures?

Have you ever been in a car accident?

Have you ever been hospitalized?

Are you currently a smoker?

Did you smoke previously?

If yes (fractures) - where?

If yes (accidents) - when?

If yes (hospitalized) - when?

If yes (smoker) - how much?

If yes (smoked) - how much?

Have you ever been diagnosed with the following? (Select all that apply)

Cancer
HIV/AIDS
Hep A/B/C
Other

If you selected Other, please add more details

Medications (list):

Doctor’s notes:

Currently on birth control pills/patch? (if applicable)

# of pregnancies (if applicable)

Are you pregnant? (if applicable)

Previously on birth control pills/patch? (if applicable)

# of children (if applicable)

If you are pregnant, when is your due date? (if applicable)

BIRTH RECORD

Were there any complications during your mother’s pregnancy or during your birth?

What type of birth did you have (vaginal, c-section, forceps, etc.)?

EXTENDED HEALTH CARE INSURANCE - DIRECT BILLING

Direct billing may be available to you. If you have Extended Health Care Insurance available, please provide the information below.

Name of Insurance

Policy Number

Member ID

Are you the insured member?

If not, please provide member’s full name and date of birth

GOALS AND EXPECTATIONS

People visit a chiropractor for a variety of reasons. To serve you better, we’d like to know which of the following health care options you are most interested in and intend to follow through with. Please check which description suits you best *

Preventative Care - Wellness and life enhancement care
Maintenance Care - Removing symptoms and their cause, with periodic routine maintenance visits
Relief Care - Band-aid care to remove symptoms only
Unsure - I would like the doctor to select the type of care that is most appropriate for my condition

Muller Chiropractic is committed to providing all our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen. Please contact us at least 24 hours before your scheduled appointment to notify us of any changes or cancellation. To cancel a Monday appointment, please call our office by 2:00 p.m. on Friday. If prior notification is not given, a missed appointment fee is applied (the correspondent fee of the missed treatment). If you miss or are not able to attend your appointment, Dr. Muller will offer a virtual appointment, where recommendations on exercises and/or stretches will be sent to you through video call, phone call, and/or email. *

I agree with the terms above

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