Health History

We offer our paperwork on line so you can complete it in the convenience of your own home. Here are the essential forms we use and why we need them.

Health History and Future

This let’s us know what’s happened, but perhaps more important, where do you want to take your health?
  Download & Print Form

Worker’s Compensation

If your health issue is the effect of an injury at work, this information will help us help you.
 Download & Print Form

Auto Accident

If your health issue is the effect of an injury suffered in an auto accident, this information will help us help you.
 Download & Print Form

Neck Disability Index / Revised Oswestry Low Back Pain Questionnaire

If you have received chiropractic care elsewhere, or have medical records we will need from another practitioner, please sign this release.
 Download & Print Form

Symptom Survey Form

The Symptom Survey is a questionnaire of symptoms that correlate with the many organs and glands of your body. With this information we can build an individualized program designed to support your primary concerns and health goals.
 Download & Print Form

Acupuncture Form

When seeking acupuncture care, there are some specific questions that will help us provide excellent care when you are in our office.
 Download & Print Form

Free AdobeReader®

Each form is a PDF document file. If you do not already have AdobeReader® installed on your computer, click the Adobe® image to download for free.

First State Health and Wellness | 1536 Kirkwood Highway, Newark, DE | (302) 454-1200