Skip to content

DR. STEVE MILLIGAN

Board Certified Chiropractor in Atlas Orthogonal Chiropractic

Fall River Mills Location Call or Text: (530) 355-1610

  • Home
  • New Patients
    • Getting Started
    • Insurance Disclaimer
    • Online New Patient Form
    • Download New Patient Form
  • Contact
  • Dr. Steve
  • Must See
    • Doc & the Atlas
    • Conditions Helped
      • Videos
      • Improved X-Rays
      • Published Articles
  • Testimonials
  • Location
  • Insurance Disclaimer

CONFIDENTIAL HEALTH INFORMATION

Please allow our staff to photocopy your driver's license and insurance details. All information you supply is confidential. We comply with all federal privacy standards.

Step 1 of 4

25%

Personal Details

Have you consulted a chiropractor before?
When?
Name
Gender
Birth Date
Address
Marital Status
Do you have children?
Please enter a number from 0 to 20.

Employer Info

Your Employer Address

Medicare Section

Do You Have Medicare
Insured's Name

Symptom Section

2. And are the result of:
3. Onset (When did you first notice your current symptoms?)
4. Intensity (How extreme are your current symptoms?) 0 = Absent , 5= uncomfortable, 10 = Agonizing
5a. How often do you feel it?
5b. How long does it last?
6. Quality of symptoms (What does it feel like?)

9. Aggravating or relieving factors (What makes it better or worse, such as time of day, movements, certain activities, etc.)

10. Prior interventions (What have you done to relieve the symptoms?)

12. How does your current condition interfere with your:

13. Review of Systems

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select any condition that you've Had or currently Have.

a. Musculosketatal

Osteoporosis
Knee injuries
Arthritis
Foot/ankle pain
Scoliosis
Shoulder problems
Neck pain
Elbow/wrist pain
Back problems
TMJ issues
Hip disorders
Poor posture

b. Neurological

Anxiety
Depression
Headache
Dizziness
Pins and needles
Numbness

c. Cardiovascular

High blood pressure
Low blood pressure
High cholesterol
Рoor circulation
Angina
Excessive bruising

d. Respiratory

Asthma
Арпеа
Emphysema
Hay fever
Pneumonia
Shortness of breath

e. Digestive

Anorexia/bulimia
Ulcer
Food sensitivities
Heartburn
Constipation
Diarrhea

f. Sensory

Blurred vision
Ringing in ears
Hearing loss
Loss of smell
Chronic ear infection
Loss of taste

g. Integumentary

Skin cancer
Psoriasis
Eczema
Acne
Hair loss
Rash

h. Endocrine

Thyroid issues
Immune disorders
Hypoglycemia
Frequent infection
Swollen glands
Low energy

i. Genitourinary

Kidney stones
Infertility
Bedwetting
Prostate issues
Erectile dysfunction
PMS symptoms

j. Constitutional

Fainting
Low libido
Poor appetite
Fatigue
Sudden weight change
Weakness

14. Illnesses

Check the illnesses you have Had in the past or Have now.

14. Illnesses, Check the illnesses you have had in the past or have now.
15. Operations, Surgical interventions, which may or may not have included hospitalization.
16. Treatments, Check the ones you've received in the Past or are receiving Currently.
17. Injuries, Have you ever...

18. Family History

Some health issues are hereditary. Tell Dr. Milligan about the health of your immediate family members.

Illnesses in Parents, or Siblings? Are they in Good or Poor Health?

20. Social History

Tell Dr. Milligan about your health habits and stress levels.

Alcohol use
Coffee use
Exercising
Tobacco use
Exercising
Pain relievers
Soft drinks
Water intake
Job pressure/stress?
Prayer or meditation?
Financial peace?
Vaccinated?
Mercury fillings?
Recreational drugs?

21. Activities of Daily Living

How does this condition currently interfere with your life and ability to function?/p>

Rising out of chair
Sitting
Standing
Walking
Lying down
Bending over
Climbing stairs
Using a computer
Getting in/out of car
Driving a car
Looking over shoulder
Caring for family
Grocery shopping
Household chores
Lifting objects
Reaching overhead
Showering or bathing
Dressing myself
Love life
Getting to sleep
Staying sleep
Concentrating
Exercising
Yard work
26. Describe your typical eating habits:

Acknowledgements

To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.

I instruct the chiropractor to deliver the care that, in his or her professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.(Required)
I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.(Required)
I realize that an X-ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant.(Required)
Date of last menstrual period (MM/DD/YYYY):
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.(Required)
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.(Required)
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.(Required)
Clear Signature

Get In Touch!

(530) 355-1610

We prefer to be contacted by text or telephone. :-)

43228 Highway 299 East, 
Fall River Mills, CA 96028

Additional Resources

FAQ

Privacy policy

Terms and conditions

Location

Office Hours

To be safe, By Appointment Only:

Regular Business Hours: Dr. Milligan treats patients Tuesday, Wednesday, Friday, from 9:00 to 5:00 and Saturday from 9:00 to 3:00 in Fall River Mills, CA. by appointment

 Closed Sunday, Monday, and Thursday.

 

After Hours: Please text or call 530-355-1610 for after-hours and emergencies (texting is fastest).  Typically there will be an extra $ 75.00 charge for after hour visits

© 2025 DR. STEVE MILLIGAN. All Rights Reserved.