Patient Forms and Online Resources

We've included several forms on our website. Filling these out before you show up, will save you a lot of time at the office. Also, completing the forms at your own pace means less chance for errors. You will need a PDF viewer, such as Adobe Acrobat Reader, to view and print the forms.

Note: Certain types of insurance require their own specific forms. When in doubt, contact our office to find out which forms you will need.

Forms

• New Patient Intake Form - For patients who are being seen for the first time in the office. It reviews you current complaints, health history, and billing information.
• Pain Form - Used for all patients, new and existing. This is a body diagram to mark the location and quality of your symptoms.
• Existing Patient Update Form - Used for established patients that have a new condition, flare-up of old conditions or re-evaluation.
• Nutritional Symptom Survey - Used for nutritional consultation patients. The form reviews many aspects of your health. It may look lengthy, but can be filled out quickly.

Informational Links

• http://www.oscachiro.org
  Ohio State Chiropractic Association - general chiropractic information
• http://www.amerchiro.org
  American Chiropractic Association - general chiropractic information
• http://www.icpa4kids.com
  International Chiropractic Pediatric Association - chiropractic care for children
• http://www.standardprocess.com
  Standard Process - whole food supplementation
• http://www.bioticsresearch.com
  Biotics - whole food supplementation
• http://www.909shot.com
  National Vaccine Information Center - vaccine awareness information
• http://www.mercola.com
  Dr. Joe Mercola - healthy lifestyle information

Professional Referrals

• Acupuncture, Craniosacral - Committed to helping you achieve physical, emotional, and spiritual well-being.
• Mimi Tagher, LAC, LMT
• Inner Bridges
• (859) 466-4900
• 114 Wellington Pl
  Cincinnati, OH 45219
• www.innerbridges.com     fflyer@prodigy.net

• EMDR, Psychotherapy - Frees you from the limitations caused by trauma, large or small.
• Ruth Ellerbusch, MA, LPC, EMDR II
• Ruth Ellerbusch, LLC
• (513) 736-5829
• 11223 Cornell Park Dr
  Blue Ash, OH 45242
• www.ruthellerbusch.com     ruthcarol@go-concepts.net

• Hypnotherapy, Guided Imagery - Experience freedom from anxiety and unwanted habitual patterns; heal within.
• Sherry McHenry, CCHt
• Inner Dimensions of Health
• (513) 924-5329
• 5400 Kennedy Ave
  Cincinnati, OH 45213
• www.innerchange4u.com     sherrymchenry@fuse.net

• Massage
• Cindy Kane, LMT
• Stillpoint Center
• (513) 489-5302 ex 94
• 11223 Cornell Park Dr #302
  Blue Ash, OH 45242
• www.stillpointtherapy.com     cdykane2002@yahoo.com

• Massage, Energy Work - Holistic and Spiritual services that help people through this journey called 'Life'.
• Paula Posival, LMT
• Soul Wisdom Discovery Center
• (513) 683-1422
• 10084 State Rt 48
  Loveland, OH 45140
• www.angelfire.com/ohs/soulwisdom

• Massage, Therapeutic & Medical - Highly intuitive massage therapist employing a variety of therapeutic massage techniques to unblock muscles and to address chronic stress.
• Anya Feldman
• Anya Feldman, LMT
• (513) 792-9226
• 8416 Wicklow Ave
  Cincinnati, OH 45236