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Chiropractic Intake

Welcome to Roland Park Chiropractic. We are looking forwards welcoming you in our small clinic and therefore community.

Please fill out attached questionaire as with much detail as possible. Dr. Laub will utilize this form as a basis to get to know you and this background info is important to draft the perfect treatment plan specifically for you.

Please also write down all questions you might have. Your initial appointment is 90 minutes to build a strong relationship.

Again we are excited to see you!

Personal Info
Contact Info
Emergency Contact
Doctor
Other
Current Health History
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No Pain/DiscomfortSevere Pain/Discomfot
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No PainSevere Pain
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Medications
Injuries
Surgeries
Conditions
Head & Neck
Chest, Lung, Heart & Skin
Internal, Digestive & Miscellaneous
Gynecological (Females Only)
Mental Health
Review & Agree