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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

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

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Office Hours

Los Alamitos Office


8:00 am-12:15 pm

2:30 pm-6:15 pm


2:30 pm-6:15 pm


8:00 am-12:15 pm

2:30 pm-6:15 pm




8:00 am-12:15 pm

2:30 pm-5:00 pm






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