Cigna/ASH Health History Form

Please fill-out the form to the best of your ability.  We will review all the information at your visit. 
***If a question is required but you don’t have an answer, you can respond with “N/A.”***

Cigna/ASH - New Patient History
How often are your symptoms present? *
In general would you say your overall health right now is: *
Please check all of the following that apply to you (If yes, explain in next section):: *
Family History: *
I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary. *