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Online Forms

Anderson Hamo Chiropractic offers our patient form(s) 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.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Electronic Health Records Form- Required

Electronic Health Records Intake Form

In compliance with requirements for the government EHR incentive program

First Name:_________________________

Last Name:_________________________

Email address:  [email protected]_________________

Preferred method of communication for patient reminders (Circle one):  Email / Phone / Mail

DOB:   __/__/____         Gender (Circle one):   Male / Female      Preferred Language:  __________________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked

CMS requires providers to report both race and ethnicity

Race (Circle one):   American Indian or Alaska Native / Asian / Black or African American / White (Caucasian)  Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one):  Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name

Dosage and Frequency (i.e. 5mg once a day, etc.)







Do you have any medication allergies?

Medication Name

Reaction

Onset Date

Additional  Comments













I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.)

Patient Signature: _____________________________________________   Date:________________

For office use only

Height: _________       Weight:____________    Blood Pressure:______ /______



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