Welcome to my office.  Please take a few moments to tell me a little about you.

Last                                            First                                                          M.I.                             

Address                                                                                                                                          

City, State, Zip                                                                                                                               

Home Phone                          Alternate/Cell Phone                         Work Phone                          

Date of Birth                                         Age                             SSN                                               

Spouse                                                                             Children                                                

Occupation                                                                                                                                     

Employer                                                                                                                                        

Employer Address                                                                                                                           

Insurance Company                                                                                                                        

Policy Number                                                                                                                                

Group Number                                                                                                                                

Deductible/Co-Pay Amounts                                                                                                           

How were you referred to Dr. Avard?
               ___Yellow Pages     ___Internet     ___Newspaper
               ___Sign/Drive-By/Live or Work in the Neighborhood
               ___Insurance company directory
               ___Friend or Relative (Name)____________________________________
               ___Another Doctor or Therapist (Name) ___________________________

			Health Information

Have you had previous chiropracic care?  ___  Yes   ___ No 

Where is your pain? _______________________________________________________

__________________________________________________________________________

Is your condition the result of:     ___Working Injury     ___ Automobile Accident

Please give a brief history of your condition:_________________________________

_________________________________________________________________________

Is your pain:__Constant__Frequent__Daily__Comes/Goes__With Activity__At Rest

How long have you had this condition? _____________________________________

Have you had this or similar conditions in the past?  ___Yes   ___No

If so, please describe:_____________________________________________________

Are your symptoms:   ___Improving   ___Getting Worse   ___Staying the Same

What gives you relief from your symptoms? _________________________________

_________________________________________________________________________

What makes your symptoms worse? ________________________________________

_________________________________________________________________________

Are you currently, or have you been under the care of another doctor or therapist 

for this condition?  If so, please describe: ____________________________________

__________________________________________________________________________

What surgical operations have you had and when? ___________________________

__________________________________________________________________________

Do you regularly take any prescription or over the counter medications? ________

__________________________________________________________________________

Do you use any vitamin, mineral, herbal or glandular supplements? ____________

__________________________________________________________________________

Have you ever been in an automobile accident? ______________________________

__________________________________________________________________________

Have you ever had any other serious injury or major illness? ___________________

__________________________________________________________________________

I understand that health and accident policies are an agreement between insurance carriers and myself.
Further, I understand that Dr. Avard will prepare any necessary reports and forms to assist me in 
making collection from the insurance company or other responsible party and that any amount authorized 
be paid directly to Dr. John B. Avard will be credited to my account on receipt.  However, I clearly 
understand and agree that all services rendered me are charged directly to me and that I am personally
responsible for payment.  I also understand that if I suspend or terminate my care and treatment, any 
fees for professional services rendered me will be immediately due and payable.

Patient's Signature ____________________________________________________

Parent/Guardian's Signature ____________________________________________

Date__________________________________________________________________