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/clients/4292/documents/FMU_History.pdf

Steven B. Wasserman, R. N., D. C. offers our patient form(s) online so you can complete it in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Bring your printed and completed form(s) to your appointment or Fax them to (562) 430-7544.

New Patient Health History Form - Required

This let's us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!  

Forms to Download for:

Cash/No Insurance:  1, 2, 6

PPO/Insurance:  1, 2, 3

Medicare:  1, 2, 8, 9, 10

Out of Network PPO/Insurance:  1, 2, 7

HMO/Monarch:  1, 2, 4

Personal Injury:  1, 2, 11, 12, 13, 14, 21

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Download and Print Forms:

1. New Patient Information

2. Health History

3. PPO Financial Policy

4. Monarch IPA Financial Policy

5. Managed Care Policy

6. Cash Financial Policy

7. Out-of-Network Financial Policy

8. Medicare Financial Policy

9. Medicare Non-coverage ABN Form

10. Simplified Medicare Explanation of Benefits

11. PI/Auto Accident Financial Policy

12. Auto Accident History Form

13. Auto Accident Symptom Survey

14. Pain Scale-VAS

15. Non-Covered Additional PT Services

16. Pain chart

17. Neck questionnaire

18. Low back questionnaire

19. Upper extremity questionnaire

20. Lower extremity questionnaire

21. Auto Insurance Verification 

22. What to Expect after a Chiropractic Adjustment

23. Functional Nutritional-Wellness Financial Policy

24. Functional Nutritional-Wellness Liability Waiver

25. Functional Nutritional-Wellness Health History

26. Out of Network Financial Policy (BC, etc.)

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Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



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Services
We strive to provide complete care for our patients. Learn more about all the services we provide.
Make An Appointment
drsw@adjustm.com
If you would like to request an appointment please click above "Make An Appointment". We will reply within 12-24 hours or call our office or leave a message at (562)430-4949 and we will return your call.
Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.