Patient Intake Form

Introduction

Welcome to Kozik Chiropractic Dr John J Kozik's patient intake form. We are delighted that you have chosen us as your chiropractic care provider. This form plays a crucial role in establishing your medical history and understanding your current health condition. By providing us with accurate and detailed information, you will help our team deliver the best possible care tailored specifically to your needs.

Why Fill Out a Patient Intake Form?

The patient intake form serves as an essential tool for both you and our clinic. It allows us to gather vital information about your medical history, existing conditions, and any concerns you may have. This data helps Dr John J Kozik and our team evaluate your health accurately and provide appropriate treatment.

About Kozik Chiropractic

Kozik Chiropractic, headed by Dr John J Kozik, is a reputable chiropractic clinic that focuses on improving the overall well-being of our patients. With a passion for providing holistic and non-invasive solutions, we aim to alleviate pain, enhance mobility, and promote optimal health through chiropractic care.

How to Fill Out the Patient Intake Form

Filling out the patient intake form is quick and easy. Below, you will find various sections in the form. Please take the time to complete each section with accurate and detailed information. Remember, the more information you provide, the better we can understand your unique health needs and tailor our services accordingly.

Section 1: Personal Information

In this section, we kindly ask you to provide your personal information. This includes your full name, date of birth, contact details, and insurance information if applicable. Rest assured that all information shared will remain confidential and will only be used for medical purposes.

Section 2: Medical History

Please provide a comprehensive overview of your medical history in this section. Include any previous or current medical conditions, surgeries, injuries, or allergies. It is crucial to disclose any medications or supplements you are currently taking.

Section 3: Present Concerns

Describe your specific health concerns and the reason for seeking chiropractic care. If you are currently experiencing pain or discomfort, please provide relevant details such as the duration, severity, and any triggering factors.

Section 4: Lifestyle and Habits

Here, you will have the opportunity to inform us about your lifestyle and daily habits. This information helps Dr John J Kozik better understand the factors that may contribute to your overall well-being, including diet, exercise, stress levels, and any habits or activities that may impact your health.

Section 5: Goals and Expectations

Describe your goals and expectations for chiropractic care. Whether you are seeking pain relief, improved mobility, or enhanced overall wellness, clearly communicating your objectives allows us to create a personalized treatment plan that aligns with your desired outcomes.

Submitting the Form

Once you have completed the form, you can submit it electronically through our secure patient portal. If you have any questions or need assistance while filling out the form, please do not hesitate to contact our friendly staff.

Conclusion

Thank you for taking the time to complete Kozik Chiropractic Dr John J Kozik's patient intake form. Your cooperation in providing accurate and detailed information empowers us to deliver exceptional chiropractic care tailored to your specific needs. We look forward to welcoming you at our clinic and helping you achieve optimal health and well-being.