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Name (First Name, Last Name)
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Date of Birth (mm-dd-yyyy)
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Address (Street Address, City, State / Province, Postal / Zip Code)
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Phone Number
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Text Reminders?
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Email Address
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Date of last visit to our Center:
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Has your insurance changed?
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Type of Insurance
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Please enter your insurance contract number here
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Insurance Subscribers Date of Birth
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1.) To the best of your recollection, for what reason had you decided to leave our office initially?
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2.) Please describe your health status since your last visit to our clinic including, visits to other doctors or hospital stays:
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3.) Please state medications and/or supplements you are/have taken, motor vehicle accidents and/or any work related injuries:
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4.) Have you had any major lifestyle changes since your last visit (eg. marriage, children, employment)?
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5.) What is your reason for today’s visit?
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6.) Is there anything else you would like us to know?
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Signature
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Date Signed (mm-dd-yyyy)
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