Online Form in Edmonds, WA Chiropractor

Welcome to Optimal Health Chiropractic and Massage's online Patient Intake Form. Please use the link below and fill out our online form, your information will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs.

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Nature of Injury
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Have you ever had same condition?
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Have you ever been under chiropractic care?
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Do you have health insurance?
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Have you been treated for any conditions in the last year?
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Is there a chance that you are pregnant?
Have you had X-rays taken?
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Broken bones?
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Been hospitalized?
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Been in auto accident?
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Had Sprains/Strains?
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Been struck unconscious?
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Had surgery?
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Do you experience pain every day?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Do changes in weather affect your symptoms?
Do you wear orthotics?
Do you take vitamin supplements?
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Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
Have you ever suffered from:

Please do not submit any Protected Health Information (PHI).

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    Contact Us

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    Please do not submit any Protected Health Information (PHI).

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      Location

      Find us on the map

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      Primary Location

      Address

      7315 212th St SW #203
      Edmonds, WA 98026

      Contact Information (425) 361-1839

      Monday  

      9:00 am - 6:00 pm

      Tuesday  

      9:00 am - 6:00 pm

      Wednesday  

      9:00 am - 6:00 pm

      Thursday  

      9:00 am - 6:00 pm

      Friday  

      9:00 am - 6:00 pm

      Saturday  

      Closed

      Sunday  

      Closed