Ciccone Family Chiropractic – A Wellness Way Affiliate

New Patients

Thank you for considering Ciccone Family Chiropractic – A Wellness Way Affiliate for your health needs. Let’s get started!

These forms cannot be filled out using a tablet or mobile device as they are not compatible…Thank you!

Questions about the process of becoming a Wellness Way patient? New Patients, please review our frequently asked questions!

PLEASE NOTE! PDF files must be saved to your desktop before and after completing!

Step 1


Complete the Health History Questionnaire. Email this document to lancaster@twwclinics.com.

Health History Questionnaire

Attention Parents/Guardians: If you have a child age 10 or under, you will need to print out and complete the Pediatric History Form and not the Health History Questionnaire listed above. Bring this form with you to the office for your first appointment!

Pediatric History

Step 2


Print out and complete the Signature Pages. Bring these forms with you to the office for your first appointment!

Signature Pages

Step 3


Complete the Functional Assessment Questionnaire online. This health review takes approximately 30 to 40 minutes to complete. Once you have completed this form, click the Submit button and it will be electronically sent to us.

Functional Assessment Questionnaire