Check "P" for Past, "C" for Current – if past and current, check both boxes.
If it does not apply, please check the P for None in this Category.
Many of the following conditions respond to Chiropractic Care.
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care in accordance with this state’s statues.