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Thank. See you soon at your scheduled appointment!

Welcome to Palm Beach Chiropractic & Rehabilitation.

Please carefully complete the following health questionnaire.





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Emergency Contact Info

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Complaint 1

Quality of Discomfort

scale from 1-10 (10 being the worst)

[item-272_quantity]
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Auto accident


Yes
No

Motor Vehicle Accident Health History






The Accident




Medical History



Thank you for taking the time to fill out this accident questionnaire. This information is important in the doctor obtaining a clinical
picture so as to make an appropriate diagnosis and treatment plan. Please sign below authorizing that the information in this
form has been read and filled out completely and accurately to the best of your understanding. Also, understand that the
information in this form is considered confidential and for use by your doctor at Palm Beach Chiropractic and Rehabilitation, Inc.

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Insurance Information

Please enter your information as shown on your insurance card.

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Personal Health History




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Social History


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Review of Systems & Medical History

Please mark any of the following conditions that apply to you, past or present











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Family Health History

Does anyone in your biological family (parent, grandparent, sibling, or child) have a history of?


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Complaint 3

Quality of Discomfort

scale from 1-10 (10 being the worst)

[item-432_quantity]
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Complaint 2