Insurance

February 2, 2009

Most insurance plans are accepted at our office. Listed on this page are some of insurance companies we accept. If you do not see your insurance provider listed, or are unsure of your coverage, do not hesitate to call us. Our staff will verify and explain your benefits before treatment, at no charge. We also offer affordable cash plans if you do not have insurance or  your insurance is not accepted in our office. 

Please check with the office for current information.

  • Most major medical PPO polices
  • Blue Shield PPO Providers

 
  • Auto Accident/Personal Injury
  • Lein accepted with attorney authorization

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Appointments

February 2, 2009

Appointments

Fill out the following form to schedule an appointment with our office. We will confirm the appointment via email.

 

(Please Note: Your privacy is 100% assured.)
* Name:
* Street Address:
* City:
* Email:
* Daytime Phone:
Evening Phone:
Referred By:
Preferred appointment time:
(We will try to accommodate your requested time.)
Time Day Month


am 

pm

Optional:
Print and complete required formsto expedite your office visit.
Optional:
Complete the area below if you would like us to check yourinsurance coverage:

Comments:

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Stress Test

February 2, 2009

The purpose of this stress survey is to determine if any health problems you may be having are due to stress.

* indicates required information.

 

*Name
*Age
*Phone (Home)
*Work
*Address
*City, State, Zip
*E-mail Address
*Occupation
# Hours per week
currently working
Spouse Occupation
# Hours per week
currently working

 

By completing this survey, you qualify to receive a new patient information packet.

1) Check off any of the following symptoms you have experienced in the past 6 months:

 

 Headache/Tension

 Fatigue/Tired

 Pain Anywhere in Body

 Digestive Disturbance

 Difficulty Sleeping

 Irritability

 Low Back Pain

 Neck Pain

 Wrist/Hand Pain

 Elbow Pain

 Shoulder Pain

 Hip Pain		  Pain Between Shoulders

 Knee Pain

 Ankle/Foot Pain

 Ringing in Ears

 Nervousness

 Dizziness

 Allergies

 Tension Across Top of Shoulders

 Numbness/Tingling in Arms or Hands

 Numbness/Tingling in Legs or Feet

 Weight Trouble

 Other 

Which of the above bothers you the most?

How long have you been bothered by this condition?

Describe how it feels or affects you when it is at its worst.

2) Do the symptoms cause you you to be:

 Moody

 Irritable

 Interrupts Sleep

 Restricted on Daily Activities

3) In what ways do the symptoms affect your work? 

 Difficulty Making Decisions

 Poor Attitude

 Decreased Productivity

 Exhausted at End of Day

 Unable to Work Long Hours

4) How does this affect your life?

 Lose Patience with Spouse or Children

 Restricts Household Duties

 Hinders Ability to Exercise or Participate in Sports

 Interferes with Ability to Participate in Hobbies or other Desired Activities

If you checked any of the above items, then you could be suffering from:

· Excessive Stress ·
· Structural Misalignment ·
· Pinched Nerves ·


We Can Help You because we gently treat your body, naturally, without drugs to remove the stress and imbalances that Cause health problems.Would you like to get rid of the problem? 
 Yes   
 No
If your answer is Yes, there are alternatives available to you. Please check the item most appropriate for you.

 

I would like to come to Family Life Chiropractic for a complete evaluation. Please call me to schedule an appointment.
I would like to come to a class on Stress and Wellness.
I would like Family Life Chiropractic to call me to discuss my health problems before making an appointment.
I am interested in receiving more information from Family Life Chiropractic.

 


 


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