New Patient Forms - Required

Adult Health History Form for Complex Disorders:

Adult Biomedical Intake Form
Adult Biomedical Health History Form

These forms are to be filled out by individuals seeking natural biomedical care for complex chronic health disorders, including but not limited to: Widespread Pain Syndrome, Fibromyalgia, Chronic Fatigue, Depression, Anxiety, Early Memory Loss, Neurological Disorders, Metabolic Syndrome and Cardiovascular Issues. This clinic does not provide behavioral therapy or psychological counseling which must be part of your total care. The clinic's focus is on promoting optimal nervous system function.

Child Health History Form for Autism and ADHD:

Peds Biomedical Intake Form
Peds Biomedical Health History Form

These forms are to be filled out by parents seeking biomedical care for an infant, child or adolescent with complex chronic health disorders, including but not limited to: autism, Asperger's, ADHD, ADD, learning disabilities, mood and behavioral disorders, asthma, digestive disorders, and metabolic syndrome. This clinic does not provide behavioral therapy or psychological counseling which must be a part of your child's total care. The clinic's focus is on promoting optimal nervous system function.

Chiropractic Care Form:

Structural/Orthopedic Care Intake Form

To be filled out by individuals seeking care for basic chiropractic/orthopedic disorders. For those individuals with a more complex chronic disorder (e.g. wide spread pain syndrome, fibromyalgia, depression, digestive disorders, metabolic syndrome) please fill out our comprehensive biomedical care questionnaire, any questions please call us.

For Financing Options and to see if you qualify for 0% interest financing click on the Flexible Payment Plans Blue Rectangle to the right.
With chronic pain or broken brain, pinpointing the actual cause of your injured nervous system is a bit like CSI detective work. A thorough and comprehensive examination of all facts is necessary to solve the mystery of your chronic health issues. For this reason we utilize detailed questionnaires to gather all pertinent clues. If you wish to attain real healing here is where the journey begins!

Pain and Brain Privacy Practices Form

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Pain & Brain Healing Center offers our patient forms online so they can be completed it in the convenience of your own home or office.

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Download the necessary form(s), print it out and fill in the required information.
• Fax us your printed and completed form(s) or bring it with you to your appointment.
  

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