Contact Discover Specific Chiropractic

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Emergency
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List present complaints, injuries and duration:
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Have you had Chiropractic care before?	Yes No
Do you have health insurance?	Yes No
Is it possible you are pregnant?	Yes No
Are you here for care because of :	An auto accident
	An on the job injury
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Please explain:
Date of your last physical examination:
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Are you on Medicare?	Yes No
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Please list all accidents, falls, broken bones, injuries, surgeries, major illnesses TYPE DATE DESCRIBE/COMMENTS

Are you presently taking any medication? NAME OF DRUG ATM DESCRIBE/COMMENTS

Directions

Physical Address:
4101 Main Street
Suite A
Hilton Head Island, SC 29926

Mailing Address:
PO BOX 21830
Hilton Head Island, SC 29925

(843) 689-CARE (2273)