( McDermott Chiroprac tic )
Secure Online Appointment Form

Please complete & Press Submit at the Bottom   |  Note:  are required fields


Personal Information
First Name: Last Name:
Middle Initial: Email:
Street Address: City:
State: Zip:
Home Phone: Work Phone:
Spouse's Name Social Security #:
Age: Birth Date

Marital Information (Please Select One)
Marital Status:                     Single: Married: Widowed: Separated: Divorced:

Employer Information ( If Applicable )
Employed By:
Business Address:
Occupation: Business Phone:

Referral Information
Friend Family Member Co-Worker Name: 
Clinic Location Yellow Pages Mail Other: 

Payment Information
Cash Check Credit Card
Health Insurance Automobile Insurance Workers Compensation

Primary Insurer Information ( If Applicable )
Medical Insurance: No Yes
(If Yes) Primary Insurer: Contact Number:

( Medical / Family History )    S=Self M=Mother F=Father
(Please indicate which conditions have been experienced by the above by marking appropriate boxes)
  S     M      F   S     M      F   S     M      F   S     M      F
AIDS Dislocated Joints Neck Pain Anemia
Epilepsy Nervousness Arthritis German Measles
Numbness Asthma Headaches Polio
Back Pain Heart Trouble Poor Circulation Bladder Trouble
Reproductive Disorders Hepatitis Bone Fracture High Blood Pressure
Rheumatic Fever Cancer HIV/ARC Rheumatism
Chest Pain Kidney Disorder Scarlet Fever Concussion
Bowel Control Loss Serious Injury Convulsions Menstrual Cramps
Sinus Trouble Diabetes Multiple Sclerosis Tuberculosis
Indigestion Muscular Dystrophy Venereal Disease

Treatment History
Have you been treated by a physician for any health condition in the last year ?  Yes   No
Describe Condition Date of Last Physical Exam

Surgical History
1. Date:
2. Date:
3. Date:

Have you ever had a metal implant?No Yes

Accident History
Job Auto Other
1)  

Job Auto Other
2)  

Job Auto Other
3)  


Please Describe Present Major Complaints  (Rate Your Symptoms (1-10, with 1 being lease serious )
1. 2. 3. 4.
5.
6.

Symptoms  
Symptoms Are Worse In: Morning    Afternoon    Night   
Symptoms Developed From: Job Injury    Auto Accident    Other    Accident    Illness Unknown Cause    Gradual Onset   
Symptoms / Complaints: Come and Go    Are Constant   
Have You Ever Had This Before: No    Yes   
Symptoms have persisted for: Hour(s) Days(s) Weeks(s) Month(s) Year(s)

If you were to guess, what do you think is causing your complaints?

Name and location of doctors previously seen for present condition(s)

Are you allergic to any medications  NO  Yes    What Kind ?


Are you taking any medications  NO  Yes    What Kind ?


Are you pregnant    Yes    Date of Last Menstrual ?

Please Check the following activities that aggravate your condition:
Bending Reaching Straining at the Stool Coughing Sitting Turning Head Lifting Sneezing Walking Lying Down Standing

Please check the activities that relieve your condition:
Bending Sitting Lifting Standing Lying Down Turning Head Reaching Walking

Please check all symptoms you may be experiencing
Blurred Vision
Buzzing In Ears
Cold Feet
Cold Hands
Cold Sweats
Concentration Loss/Confusion		 Constipation
Diarrhea
Dizziness
Face flushed
Fainting
Fatigue		 Fever
Head seems to Heavy
Headaches
Insomnia
Light bothers Eyes
Loss of balance		 Loss of smell
Loss of taste
Low resistance to colds
Muscle jerking
Numbness in fingers
Numbness in toes		 Pins and needles in arms
Pins and needles in legs
Ringing in ears
Shortness of breath
Stiff neck
Stomach upset

Emergency Information ( All Fields Required )
Emergency Notification Phone:

Other Information ( Please Complete )
How did you learn of our practice: