Special Offer - Tuck Clinic

We have a special offer for you as our guest to our webpage.

To start the process of determining if your condition is one we can help, we ask that you fill out the following pre-visit evaluation. Or if you prefer, click here for a printable certificate that you can bring into any of our office locations to take advantage of this offer.

Please note: All boxes need to be completed before submitting. If a question is not applicable please type "no", "none" or "does not apply".

Name:

Date of Birth:

Daytime phone #:

Evening phone #:

Primary care physician:

Date of last physical exam:

What operations have you had and when?:

Have you had any serious illnesses or injuries? If any, when did you have them?:

Have you had any broken bones?:

Have you been treated for any health condition by a physician in the last year?:

If female, are you currently pregnant?:

Present Complaint:

Date the problem started:

Was there a particular event that caused pain or problem?:

Pains are:

What aggravates your condition/pain?:

What activities lessen your condition/pain?:

Is condition worse during certain times of the day?:

Is this condition interfering with work?:

Is this condition interfering with sleep?:

Is this condition interfering with routine?:

Is this condition interfering with other activity?:

Is condition getting progressively worse?:

Other doctors seen for this condition:

Have you used any home remedies?:

What medications are you currently taking?:

Which clinic is most convenient for you?:

Site Disclaimers:

I have read and understand the disclaimers of this web site
Please note, submitting this form does not substitute for an office consultation. By submitting this form no Doctor-Patient relationship is formed with Tuck Chiropractic Clinic. We will require you to come in for an in-office consultation. This will ensure that any care we provide is customized for each patient. It is important to remember that any information received through this web site and E-mail cannot be guaranteed to be confidential because of the possibility that a third party could intercept the message. Of course, once our office receives the information, it will be maintained in the strictest of confidence.