Groupon Intake

1930 S Bascom Ave Suite 230, Campbell, CA 95008 

(408) 340-5055  |  LifeGiving-Chiro.com  |  [email protected]


New Patient Intake Form

Groupon

Groupon Appointments

Please Read:

Our discounted services provided through are done as a public service to allow patients who may be new to Chiropractic Care or  Therapeutic Massage.

We provide these services at a discounted rate to allow patients to experience these services at an affordable rate. While our services are discounted through Groupon our office still provides the standard of care afforded to all of our patients. We always maintain a high standard of detailed, personalized and high quality level of service. No matter how are patients are referred. You may have been referred through Groupon, however 95% of our new patients are referred by our thousands of satisfied patients who have referred their friends and family members to us.

These services are offered for those who are seriously seeking treatment. As we take the care of our patients very seriously. We are detail oriented and only provide the highest standard of Chiropractic services. We do not perform random spinal manipulation, which is dangerous and irresponsible. We only provide specific Chiropractic Adjustments. Which requires detailed analysis before a patient is treated. While pain relief may be provided for our patients, through the use of therapy modalities on the first day, no spinal adjustments will be performed until after a proper diagnosis has been established, spinal subluxations have been identified and the doctor has accepted your case for treatment.

Please note:

Groupon Vouchers do not apply to the treatment of Accidental Injuries or patients who require Emergency Care.

Groupon vouchers are only for New Patients to our office. For those new to our services and for those who wish to experience our standard of care.

Groupon Vouchers may only be used one time per patient. If you wish to have additional care, you may discuss our discounted rates with our staff.

24 Hour Notice is Required prior to Cancelation of an appointment. Groupon Appointments may only be rescheduled One time.

Personal Information


Health History

Please check any conditions you currently have or have had:


Family Health History

Check if any family members have a history of:

HIPAA PRIVACY PRACTICES ACKNOWLEDGMENT

I acknowledge Life Giving Chiropractic's Notice of Privacy Practices and I also understand that my personal health information is protected by HIPAA and may only be disclosed for treatment, payment, or healthcare operations.


Patient Quality of Life Survey

Please take several minutes to answer these questions so we can help you get better.

(Please check all that apply)

How have you taken care of your health in the past?
How did the previous method(s) work out for you?
How have others been affected by your health condition?
What are you afraid this might be (or beginning) to affect (or will affect)?
Are there health conditions you are afraid this might turn into?


Wellness Evaluation

Note: In medicine today, leaky gut aka intestinal permeability isn't typically diagnosed. However, that doesn't mean it's not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this evaluation to help our doctors determine how we can help your condition.

                                                                                                                  

Let's get started

Please check any that apply to you

Sub-Clinical Symptoms Including:

Autoimmune Conditions Including:

Headaches
Diabetes Mellitus
Migraines
Lupus

Hormone Imbalance Including:

Rheumatoid Arthritis
Premenstrual Syndrome
Fibromyalgia
Emotional Imbalance
Chronic Fatigue

Gastrointestinal Issues Including:

Thyroid Conditions Including:

Abdominal Bloating, Cramps or Painful Gas
Hashimotos
Irritable Bowel Syndrome
Hyperthyroidism
Ulcerative Colitis
Hypothyroidism
Crohn's Disease

Developmental and Social Concerns Including:

Condiciones Respiratorias, Incluyendo:

Autism
Chronic Sinusitis
ADD/ADHD
Asthma

Skin Conditions Including:

Allergies
Eczema

Joint Conditions Including:

Skin Rashes
Knee, Shoulder or Spine
Hives



Check the number that most closely fits, then add up your results: 

[0 = None 1 = Mild 2 = Moderate 3 = Severe]

Thank you for taking the time to fill out this form.

Location

Find us on the map

Office Hours

Chiropractic

Monday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

Massage Therapy

Monday

Closed

Tuesday

Closed

Wednesday

Closed

Thursday

10:00 am - 5:00 pm

Friday

10:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Chiropractic

Monday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
Closed
Wednesday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Thursday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Saturday
Closed
Sunday
Closed

Massage Therapy

Monday
Closed
Tuesday
Closed
Wednesday
Closed
Thursday
10:00 am - 5:00 pm
Friday
10:00 am - 5:00 pm
Saturday
Closed
Sunday
Closed