New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

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Nature of Injury
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Have you ever had same condition?
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Have you ever been under chiropractic care?
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Do you have health insurance?
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Have you been treated for any conditions in the last year?
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Is there a chance that you are pregnant?
Have you had X-rays taken?
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Broken bones?
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Been hospitalized?
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Been in auto accident?
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Had Sprains/Strains?
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Been struck unconscious?
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Had surgery?
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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?
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Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
Have you ever suffered from:

Please do not submit any Protected Health Information (PHI).

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    Locations

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    Tannehill Chiropractic

    Address

    5175 Overland Ave.
    Culver City, CA 90230, USA

    Contact Information (310) 475-9111

    (310) 841-5011

    HOURS OF OPERATION

    Monday  

    Closed

    Tuesday  

    8:00 am - 5:00 pm

    Wednesday  

    9:00 am - 1:00 pm

    Thursday  

    8:00 am - 5:00 pm

    Friday  

    Closed

    Saturday  

    8:00 am - 2:00 pm

    Sunday  

    Closed