Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com

Hello!

 

Welcome to Family First Chiropractic.  We have been serving the Greater Omaha Area since July 2007; helping individuals and families of all ages reach their true health potential through the power of specific Chiropractic care.  Someone or something compelled you to reach out for a checkup with us, and know that we take that choice very seriously.  You can count on us to provide you great service from our amazing team the moment you enter our office for your first visit.  You can count on us to truly care about your current state of health and helping you with whatever we can to get it to where you want it to be.  Given you are a candidate for chiropractic care after your exam, you can count on us to provide you elite level chiropractic care utilizing the Gonstead Method by a great team of doctors.  We take great pride in the service we provide, and want you to know we look forward to meeting you and discover how we can help you.

In Health, Dr. Joel Marley (Clinic Director)

Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Other Phone
Email
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Birthdate
Nickname
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Missed work start date
Return or anticipated return date

Primary
Company
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Who Carries this Policy?
Insured's:
Name
Birth Date
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Patient Address
Phone
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City
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Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Reason for today's visit
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

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Front Left Chest

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Front Right Chest

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Front Right Ribs

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Front Left Ribs

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Front Abdomen

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Front Pelvis

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Front Right Hip

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Front Left Hip

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Front Right Thigh

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Front Left Thigh

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Front Right Knee

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Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

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Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

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Back Right Shoulder

Type of Pain
Back Left Shoulder

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Mid-Back

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Back Right Ribs

Type of Pain
Back Left Ribs

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Lower Back

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Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Personal Illness History
Surgery/Trauma History
Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

Family First Chiropractic
18041 Oak St
Omaha, NE 68130
(402) 884-4100
familyfirstchiropractic@gmail.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

It is important that our patients and we have the same health objectives concerning chiropractic care. Regardless of what a disease or condition is called we do not offer to treat it. Our only practice objective is to eliminate a major interference to the expression of the bodys internal wisdom and power. Our only method is specific adjusting to correct vertebral subluxations; which interfere with the bodys internal wisdom and power. We believe that the greatest Doctor is the one already inside of each of our patients and we only help to maximize that inherent healing power, without using drugs or surgery. Your signature verifies that the information given in this form is complete and correct and that you accept, if eligible, chiropractic care on this basis.

* Please read and agree to the terms
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Today's Date: 14 Dec 2018