Please fill out the necessary fields below in order to schedule your appointment. Step 1 of 5 20% Patient InformationPatient Name* First Last Date of Birth* MM DD YYYY Have you visited us before?*YesNoDate of First Visit MM DD YYYY Home Address* Street Address Apt / Suite City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Best number to reach you*Cell PhoneHome PhoneWork PhoneCell Phone*Home Phone*Work Phone*Employed byReferred by*Referring Physician Physical AssessmentPlease check the letter that accurately shows the affected area A B C D E F G H I J K L M N O P Reason(s) for visit. Please list them in order of importance History and SymptomsWhich of these have you ever had?Diabetes*YesNoCancer*YesNoOsteoporosis/Osteopenia*YesNoPacemaker or similar device*YesNoHigh Blood Pressure*YesNoHeart or Circulation Disorders*YesNoImmune Deficiency Disease*YesNoSeizures*YesNoDizzy Spells*YesNoRheumatoid Arthritis*YesNoNeurological Conditions*YesNoIf yes to any of the above, please explainWhat are your current symptoms?What activities make your symptom worse (ie. sitting, standing, lifting, etc)?What activities make your symptom better? History and DetailsDate of Injury/Onset* MM DD YYYY Have you had prior treatment for your current condition (injections, physical therapy, chiropractic, acupuncture, massage, etc.)?YesNoIf yes, what type(s)?Please list recent diagnostic studies (MRI, X-Ray, Cat-Scan)Please list surgeries you have had and approximate datesDo you have metal anywhere in your body; Pins/plates, or pacemaker*YesNoIf yes, please describeAre you pregnant or trying to become pregnant*YesNoHave you ever taken steroids or anti-coagulants for an extended period of time?*YesNoHave you have any unexplained weight gain or weight loss recently*YesNoList medications you are now taking ALL INSURANCE PATIENTS: PLEASE READDear valued patients: We would like to share the following policies with you so that you understand your responsibility regarding charges for the services rendered to you by our office: Dr.’s Tarek Adra, Gabriel Altman and Joy Altman are not a participating provider with most commercial U.S. insurance plans. In this office we will collect the treatment fees at time of service and can provide you with a “superbill”; a coded document that allows you to file directly with your insurance company. Your insurance company may deny coverage for a charge you thought was covered by your plan. We recommend you contact the Member Services Department of your insurance company if you have questions about what is covered and amounts you will be responsible for. Patient due balances over 30 days will be assessed a 1.5 % monthly (18% annual) service charge, unless other payment arrangements have previously been made with our office. Your signature below signifies that you understand our financial policy and your responsibility regarding charges incurred in this office.Patient/Responsible Party Signature*Date* MM DD YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.