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New Patient Intake

Back and Neck Relief Care - Dr. Jack F. Sarro D.C. (385) 389-2095

Please complete the following information before your first visit. This secure form helps us understand your health history, current concerns, and goals for care.

Patient Information

All Asterik* Fields Must Be Answered In Order To Submit Form

Marital Status

Pain Location

Where is your pain located?

Quality of Your Pain

Describe your pain. Check all that apply.
Does your pain radiate or travel?
Yes
No
Any numbness or tingling?
Yes
No

Pain Scale

How often do you have it?
How long does it last?

Interferes With

Pain interferes with:

Previous Treatment

Previous treatment for this condition?

Auto or Work Accident Information

Is this condition due to an Auto or Work Accident?
Yes
No
Type of accident:
Who have you reported your accident to?

Past Health History

If none, please type none or NA

Illnesses You May Have:
Are you pregnant?
Yes
No

Medications

Medications

Supplements

Supplements

Family Health History

Common health problems of your relatives:

Social Health History

Education Level:
Do you drink alcohol?
Do you smoke?
Do you take recreational drugs?

Review of Systems

Please check all symptoms you have now or in the past.

General Health

General

Musculoskeletal System

Muscles and Joints

Skin Health

Skin

Immune System

Immune System

Eyes, Ears, Nose, and Throat

Eyes, Ears, Nose, and Throat

Cardiovascualr System

Heart

Pulmonary System

Lungs

Digestive System

Digestive

Urinary System

Urinary

Reproductive System

Reproductive

Mammillary System

Breast

Hormonal System

Endocrine

Lymphatic System

Lymphatic and Blood

Nervous System

Nervous System

Mental Health System

Psychiatric

Please Sign and Date Below and Submit

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SCHEDULE YOUR APPOINTMENT

BACK AND NECK RELIEF CARE

5300 S 500 E - STE 15 

Washington Terrace, UT 84405

 

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Text: (385) 400-1102

PAIN RELIEF OFFICE HOURS

Monday, Tuesday, Thursday

8:30 AM - 6:00 PM

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Wednesday

8:30 AM - 12:00 PM

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Friday, Saturday, Sunday

Call or Text Office

SERVING COMMUNITIES

© 2000-2026 Dr. Jack F. Sarro, DC

Back and Neck Relief Care

Serving Weber, Davis and Morgan Counties of Utah, Including: Washington Terrace, South Ogden, Ogden, Riverdale, Roy, Pleasant View, North Ogden, Farr West, South Weber, Uintah, Mountain Green, Layton, Kaysville, Syracuse, West Haven, Harrisville, Eden, Huntsville, Bountiful, Farmington, North Salt Lake, and the Greater Salt Lake Area. 

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