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Bolt Chiropractic Family Wellness offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

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  • Fax us your printed and completed form(s) or bring it with you to your appointment.

General Intake Form

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

Download & Print Form

Welcome to 

Bolt Chiropractic Family Wellness

433 W. Channels Islands Blvd. Port Hueneme, CA 93041

Don Bolt, D.C.


Reason for this Visit

If you are experiencing any pain (neck pain, mid back pain, low back pain, etc.) & or have health problems, symptoms and/or complaints. Please list them in order of severity:

Getting Worse
Stayed Constant
Comes and Goes
Stayed the Same
Other

Previous Accidents

Medical History

Nerve Pills
Pain Killers
Muscle Relaxers
Blood Pressure Medicine
Insulin
Stimulants
Blood Thinners
Tranquilizers
Sleeping Pills
Anti-Depressants
Aspirin/ Tylenol
Birth Control
Other

Insurance Information

Current Complaints Interfere With Daily Living

The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your health condition
(pain and/or symptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms
you may be experiencing) is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to
each category by indicating the overall impact of pain in your life, not just when the pain is at its worst.

For each of the six categories of daily living listed, PLEASE INDICATE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ACTIVITIES.
0 means no disability at all, and a score of 10 means that all of the activities in which you would normally be involved have been totally disrupted or prevented by your health condition (pain and/or symptoms you may be experiencing).


        0               1               2               3               4               5               6               7               8               9               10
__________________________________________________________________________________________________________
Completely                                                                                                                                                            Totally

able to function                                                                                                                                              unable to function

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N/A
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N/A
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N/A
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N/A

If you are experiencing any health problems, please mark the exact location of your pain on the diagram below. Also describe the type and frequency of your pain. For example, dull, sharp, constant, off and on, when standing, sitting, walking, etc.

Cash
Check
Credit Card
Already Paid
Other

NOTICE: NOT ALL PATIENTS REQUIRE X-RAYS TO DETERMINE TYPE OF CARE AND LENGTH OF CARE. IF YOUR EXAMINATION WARRANTS X-RAYS ANALYSIS, THE FOLLOWING OFFICE POLICY PREVAILS:

1. All first visit charges are payable when services are rendered.

2. The fee paid for x-rays is for analysis only. We are required to maintain your original x-rays. Films may be loaned to another health provider with your prior authorization only.

Thank you for taking the time to fill out this form.



Patient Health Information Consent Form - Required

Download & Print Form


Informed Consent to Chiropractic Treatment

Download & Print Form


Personal Injury Questionnaire

Download & Print Form



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Location

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Office Hours

Our Regular Schedule

Monday:

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Tuesday:

Closed

3:00 pm - 6:00 pm

Wednesday:

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Thursday:

9:00 am - 12:00 pm

3:00 pm - 6:00 pm

Friday:

Closed

Closed

Saturday:

Closed

Closed

Sunday:

Closed

Closed

Testimonial

Reviews By Our Satisfied Patients

  • "Dr. Bolt helped me not only by adjusting my spine, but by educating me about holistic approach and overall health and wellness for life. I would recommend Dr. Bolt to others because he is the most unique chiropractor or even doctor of any kind that I have ever met."
    Emily -