Date:____________________ Patient Intake Form

First Name:_____________________________ Middle Initial:_________ Last Name:____________________________ What do you prefer to be called?___________________
Home Address:_________________________________ City, State, Zip:______________________________________ Home Phone:____________________ Work Phone:______________________ Cell Phone:______________________ Email Address:_____________________________________ Ok to leave messages on: Home Cell Work Sex: Male Female | Marital Status: Single Married Widowed Divorced Unknown Minor

Date of Birth:__________________________ Social Security Number:___________________________ Employer:__________________________ Job Description:________________________________________________ How did you hear about the doctor: ____________________________________________________________________ Spouse/Significant Other:__________________________________ Date of Birth:________________
Emergency Contact Name and Number:_________________________________________________________________ Responsible Party:
Name of person responsible for this account:_____________________________________________________________ Relationship to patient:___________________ DOB:_______________ Phone Number:___________________________ Address:_______________________________________ City, State, Zip:______________________________________


Please briefly describe your chief complaint:______________________________________________________________ When did you first notice the symptoms?_________________________________________________________________ What are these symptoms preventing you from doing?______________________________________________________

Do your symptoms interfere with:
If you are experiencing pain, is it:
Since the problem started, it is:
What makes it worse? And better, if anything?____________________________________________________________ Other Doctors seen for this problem (please list):___________________________________________________________

Work Sleep Sharp Dull

Walking Sitting Bending Lifting Comes and Goes Travels Constant Getting Better Getting Worse

About the Same

Place an “X” on the drawing to the left wherever you have pain. Beside the “X” indicate the type of pain you are experiencing:

A- Ache
B- Burning N- Numbness T- Throbbing

ST- Stabbing
SP- Spasm
P- Pins and Needles

PAIN SCALE: Please circle the number that best describes your overall pain: 0 1 2 3 4 5 6 7 8 9 10 10+


First time visit as new patient      $69.00

​Follow up visits                            $49.00

Family         under 18 @ home    $35.00

                              12 @ home    $25.00

                                1                  $20.00

Discount on first visit by attending.

​-$10 = $59. first visit.

  WORKSHOP with  Q & A              

call 816.525.1525 Monday evening 6:30pm

Bring someone who is curious or wants to know!

 I was introduced to Natural chiropractic health care in a informal presentation just like this. This is my way to help you find out for FREE!

 It changed my health and  lifestyle forever!!!!!
Join us!   Find out what chiropractic really is;  How it can help you!

Plus at this time we will discuss fees, types of care offered as support for chiropractic LIFE adjustments Family plans.  We may also schedule you for a future appointment.

The Cost-Effectiveness of Chiropractic

From:   Testimony to the Department of Veterans Affairs' Chiropractic Advisory Committee
George B. McClelland, D.C., Foundation for Chiropractic Education and Research ~ March 25, 2003

In the treatment of musculoskeletal disorders, despite the fact that most studies have not properly factored in such patient characteristics as severity and chronicity and lack the complete assessment of all direct costs and most indirect costs, the bulk of articles reviewed demonstrate lower costs for chiropractic. [9]   This pattern is consistently observed from the perspectives of workers' compensation studies, [10],   [11],   [12],   [13],   [14],   [15] databases from insurers, [16],   [17],   [18],   or the analysis of a health economist employed by the provincial government of Ontario. [19],   [20].   Other studies have suggested the opposite [that chiropractic services are more expensive than medical], [5],   [21],   [22]   but these contain significant flaws which have been refuted. [23]

The cost advantages for chiropractic for matched conditions appear to be so dramatic that Pran Manga, the aforementioned Canadian health economist, has concluded that doubling the utilization of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs. [20] When iatrogenic effects [yet to be discussed] are factored in, the cost advantages of spinal manipulation as a treatment alternative become even more prominent. In one study, for instance, it was shown that for managing disc herniations, the cost of treatment failures following a medical course of treatment [chymopapain injections] averaged 300 British pounds per patient, while there were no such costs following spinal manipulation. [24],   Imagine how failed back surgery might compare. Finally, in no cost studies to date have legal burdens been calculated, which one would expect should be heavily advantageous for chiropractic health management. 

From:   Testimony to the Department of Veterans Affairs' Chiropractic Advisory Committee


I was afraid of chiropractic ! I thought they would break my neck; at least that's what EVERYONE said.

 It's not what the masses do.  Therefore it is not really understood.

Of course, as the mass media brings to us; we go to the chiropractor, if we go when we are in PAIN.

If we feel something strained, tender or sprained.

That's a good time to go, although my first visit was for (insanely bad) tonsillitis. I got streptococcus every 4-5 weeks at age 14.  I treated it the way "everyone" else did then and now; Antibiotics.  Also, every 4-5 weeks for 4 months until I finally passed out during the last injection. By the way, all 3 doctors said they need to be removed. Sure, said I. Over my dead body. They all said, including my supportive family; they will burst and you will die. I resigned myself to dying then.

Besides, I thought they taught me NOT to let anyone take a knife to my throat.  Seriously, to me this just didn't seem logical.  It's what "everyone" did, yet to me not okay. 

My brother, whom I loved and idolized took me to a "chiropractic lay lecture," a health class-FREE.

Sure, why not.  Mean while my friends (14 years old) said they could snap my neck for me. I had no clue what they were insinuating. 

I didn't have to do anything- just listen.  Cool, I can do that.  Although,  I did ask a question.

All of this information about the Central Nervous System controlling EVERYTHING in the body made sense.  What about curing my tonsils?  NO! That was the answer I got. Hummmm, why am I here then? 

Dr Reggie Gold then said something that would change my life forever.  No, but; if the nerves in your neck that supply the tonsils for function are shut down, then chiropractic can turn them back on. Okay, how.  Dr. Reggie told me that the vertebrae misalignment /compression will interfere with the disc function causing the nerves to not work properly. Removing this interference will allow the supply of messages to be restored to the parts of which the ones I knew of were my tonsils. Now, if the material matter- the tonsil organ wasn't too far damaged to repair itself-they would heal. If not, remove them.

I returned when my tonsillitis came back-since medicine wasn't correcting the problem, just covering up the symptoms, sort of, instead I went to Dr Gold the chiropractor.

I tested it, 4-5 treatments over a couple of months and NO MORE CASES of tonsillitis. I'm 61 years old and still have functioning tonsils. Thank you God and chiropractic.

I then decided to become a chiropractor.