Online Forms

Steven B. Wasserman, R. N., D. C. offers our patient form(s) online so you can complete it in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Bring your printed and completed form(s) to your appointment or Fax them to (562) 430-7544.

New Patient Health History Form - Required

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


Forms to Download and Print   

*Please bring in the forms filled out on your first visit or fax them before your first appt. to 562.430.7544

  1. New Patient Information
  2. Health History
  3. PPO Financial Policy
  4. Monarch IPA Financial Policy
  5. Managed Care Policy
  6. Cash Financial Policy
  7. Out-of-Network Financial Policy
  8. Medicare Financial Policy
  9. Medicare Non-coverage ABN Form

  10. PI/Auto Accident Financial Policy
  11. Auto Accident History Form
  12. Auto Accident Symptom Survey
  13. Pain Scale-VAS
  14. Non-Covered Additional PT Services
  15. Pain chart
  16. Neck questionnaire
  17. Low back questionnaire
  18. Upper extremity questionnaire
  19. Lower extremity questionnaire
  20. Auto Insurance Verification
  21. What to Expect after a Chiropractic Adjustment
  22. Functional Nutritional-Wellness Financial Policy
  23. Functional Nutritional-Wellness Liability Waiver
  24. Functional Nutritional-Wellness Health History

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Office Hours

Los Alamitos Office


8:00 am-12:15 pm

2:30 pm-6:00 pm


2:30 pm-6:00 pm


8:00 am-12:15 pm

2:30 pm-6:00 pm




8:00 am-12:15 pm

2:30 pm-5:00 pm






  • "Where Experience and Compassion for Your Health
    Make a Difference."