View All Brands View Women's Health View Men's Health View My Favorite Product Selections View Details About How You Can Save More With Our Unique Super Saver Program Express Shop, The Quickest & Easiest Way To Shop
In order to provide you the best possible wellness care, please complete this form.

Patient Data
 
Name *
Date
   
Email *

(Your email will NOT be shared with any 3d parties, and is used for occasional office announcements and promotions.) 
 
   
   
Mailing Address
 
Address
City
State
Zip
Telephone (Home)
Telephone (Work)
Referred By

Age

Birth Date
Social Security #
Number of Children
Occupation 
Employer 
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer 
Spouse's Health Status
Emergency Contact
Phone
   
   
Current Complaints
 
Nature of Injury
     
Please Describe
   
Date of Injury
Have you ever had same condition? 
     
If yes, when? 
List other practicioners seen for this injury/condition
Have you ever been under chiropractic care?
     
 
   
Insurance Information
 
Name of party responsible for payment 
Phone
Do you have health insurance?
     
Name of company
   
Medical History
 
Have you been treated for any
conditions in the last year?
     
If yes, please describe 
Date of last physical exam 
Is there a chance that you are pregnant?
    
Have you had X-rays taken?
    
What medications are you taking and for what conditions (Please list dosage and amounts, etc).
What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).
 
   
   
Have you ever:
 
Broken bones?
    
Briefly explain
Been hospitalized?
    
Briefly explain
Been in auto accident?
    
 
Had Sprains/Strains?
    
Briefly explain
Been struck unconscious?
    
Briefly explain
Had surgery?
    
Briefly explain
   
   
Family History
 
Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) 
 
Do you experience pain every day?
    
Do your symptoms interfere with daily life?
    
Does pain wake you up at night?
    
Are your symptoms worse during certain times of the day?
    
Do changes in weather affect your symptoms?
    
Do you wear orthotics?
    
Do you take vitamin supplements?
    
What activities aggravate your symptoms?
   
   
Habits
 
Alcohol
      Moderate   
 
Coffee
        
 
Tobacco
         
 
Drugs
         
 
Exercise
        
 
Sleep
        
 
Appetite
        
 
Soft Drinks
         
 
Water
        
 
Salty Foods
         
 
Sugary Foods
        
 
Artificial Sweeteners
        
   
   
Have you ever suffered from:
Alcoholism Irregular Cycle
Allergies Kidney Infection
Anemia Kidney Stones
Arteriosclerosis Loss of memory
Arthritis Loss of balance
Asthma Loss of smell
Back Pain Loss of taste
Breast lump Lumps In Breast
Bronchitis Neck Pain or Stiffness
Bruise Easily Nervousness
Cancer Nosebleeds
Chest Pain/Conditions Pacemaker
Cold extremities Polio
Constipation Poor Posture
Cramps Prostate Trouble
Depression Sciatica
Diabetes Shortness of breath
Digestion Problems Sinus Infection
Dizziness Sleep problems/insomnia
Ears Ring Spinal Curvatures
Excessive Menstruation Stroke
Eye Pain/Difficulties Swelling of ankles
Fatigue Swollen Joints
Frequent Urination Thyroid Condition
Headache Tuberculosis
Hemorrhoids Ulcers
High Blood Pressure Varicose Veins
Hot Flashes Venereal Disease
Irregular Heart Beat Other:
   
 

 

 

 
Your Cart: (0) Total: $0.00
 
Share on Twitter Add to Google Plus Share on Facebook Email a Friend Share Tools
Virtual Visit Send a Message
Virtual Visit is an area where your health care professional will be able to provide you with tailored product recommendations, advice, and exclusive promotions to help save you money on professionally formulated, high potency natural health products not found in stores.
Send a private message
Awaken Wellness
7130 Minstrel Way  Suite 160
Columbia, MD, 21045, 
    Contact Us
Office Hours - notes
Mon:9am - 9pm
Tue:9am - 9pm
Wed:9am - 9pm
Thu:9am - 9pm
Fri:9am - 4pm
Sat:9am - 4pm
Sun:Closed
Home | About Us | Health Blog | Contact Us | Terms of Use & Privacy Policy | Return Policy | Patient Intake Form | FAQ's
To Order, Call (888) 821-8808
*These statements have not been evaluated by the Food & Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease.
© 2017 PureRXO. All Rights Reserved.
close
Driving Directions From: GO