Helping You Live Better, Longer, without Drugs
Dr. James G. Blakemore, DC       Dr. Vladimir Kaye, MD, QME
 159 North Raymond Avenue   Fullerton CA  92831 
Tel: (714) 871-2495      Fax:  (714) 871-3350

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   Patient History Forms

Before your first visit our office, you might be asked to fill out and print one of the following patient history forms, and bring it with you. 

Note:  the short and long forms below may be filled out online, then printed, or else printed first, then filled out by hand, if you wish.  The PDF
form is not filled out online; it is first printed, then filled out by hand.

1.  Short Form

2.  Long Form

3.  PDF Form


DISCLAIMER: No individuals, including those under our active care, should use the information, resources or tools contained within to self-diagnose or self-treat any health-related condition. Diagnosis and treatment of all health conditions should only be performed by your doctor of chiropractic or other licensed health care professional.

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