PATIENT FORMS

Please download and fill out these forms prior to office visit

Please note that this page is expressly for patients of Charles L. Blum, DC and is not to be used by the general public.  If you are not a patient of Dr. Blum you do not have authority to view or use the information on this page.

The forms on this page are used to assist Dr. Blum in gaining pertinent history information as well as to assist in better interpreting your clinical presentation.  If you have any questions please e-mail Dr. Blum at drcblum@aol.com or call the office at 310-392-9795.

 

NEW PATIENT FORM
AUTO ACCIDENT PATIENT
INFORMED CONSENT FORM

SPECIFIC CONDITION FORMS

Please download and fill out the appropriate forms related to your specific condition.

 

CHRONIC LOW BACK PAIN

GREATER THAN 4-8 WEEKS

ACUTE LOW BACK PAIN

LESS THAN 4 WEEKS

HEADACHE PAIN
NECK PAIN
JAW PAIN OR DISCOMFORT

DISABILITY FORM

JAW PAIN OR DISCOMFORT

SYMPTOM FORM

BODY PAIN SCALE