Phone: 925-292-5850
2165 4th Street
Livermore, CA 94550

Patient Information

Sex :   Male    Female

Who is Responsible for your bill:

Self : Personal Ins : Work Comp : Parent : Auto Ins : MC :

Employment Information

Emergency Information

Current Health Condition

Medications, Herbs, Supplements


Tobacco        Yes    No

Recreational Drugs ?        Yes     No  


Past Health History

Please report any past health conditions that may affect a proper diagnosis.

Major Surgeries or Operations:

Yes No      If yes explain ?

Broken Bones:

Yes No      If yes explain ?

Major falls or accidents:

Yes No      If yes explain ?


Yes No      If yes explain ?

Previous Chiropractic care:

Yes No   Name Of Doctor ?

Review of Systems

(Check all that apply)


  Heart Disease
  Chicken Pox


  Bladder trouble
  Painful Urination
  Excessive Urination
  Discolored Urine


  Menstrual problems
  Breast lumps
  Prostate problems


  Low Back Pain
  Mid Back Pain
  Neck Pain
  Arm Pain
  Leg Pain
  Joint Pain or Stiffness
  Difficulty walking
  Clicking or painful jaw

Nervous System

  Cold/Tingling Extremities


  Excessive thirst
  Weight problems
  Abdominal cramps
  Gas or bloating


  Chest Pain
  Shortness of breath
  High blood pressure
  Irregular heartbeat

  Lung problems
  Ankle swelling
  Heart problems


  Vision Problems
  Hearing Problems

Females Only

Is there a possibility that you might be pregnant ? Yes No

Consent for Treatment and Insurance Authorization

I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of Chiropractic at In Motion Sports and Family Chiropractic. I hereby assign benefits and I Understand that payment is due as services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company(excluding contractual allowance).if, after 60 days, insurance payment has not been received. I understand that the charges are my responsibility and payable immediately. Additionally, I consent to treatment as deemed necessary by the Doctor of Chiropractic at In Motion Sports and Family Chiropractic

Patient Agreement Forms

I Acknowledge, I have seen, I have access to, and agree to :

Consent For Treatment    View Form

Notice of Privacy Practice     View Form

In Motion Fee Schedule     View Form

Copyright © 2015 In Motion Sports & Family Chiropractic