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  • English (US)
  • Patient History Form

    Fill out the form carefully for registration
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  • I understand and agree to authorize the doctors at Life Enhancing Wellness Centers, LLC and/or the properly trained staff to administer examination procedures and treatments, as deemed necessary at that time:

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  • Please take a pictue of your Driver's License and your health or auto insurance card if using them at our clinic for your treatment (if no insurance skip this).  Take a picture of the front and back or scan if you have a scanner and upload those pictures below.  We accept, Medicare and most Anthem BC/BS (but NOT Healthkeepers) and most Aetna Insurances.

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  • What do you want the Doctor to help you with on your first visit?

    Where or what kind of symptom are you having?
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  • Tell the Doctor about your past injuries.

    Falls, crashes, beatings, broken bones, sprains, etc. from childhood to present, list them ALL here.
  • Auto Accidents, current and past

    If your current complaint is from a recent (30 days or less or open legal case) auto accident list details in Additional Chief Complaints comments box above. List all PAST auto accidents here.
  • Work Place Injuries

    All workers comp cases and non-reported work injuries list here.
  • Sports Injuries

    From Little League to Professional athletics and everything in between.
  • Medical History

    Operations and medications

  • Family History (Mother, Father, siblings



  • Lifestyle, Nutritional information

    Your diet affects inflammation and pain levels
  • Should be Empty: