I know there is so much controversy between chiropractic and medical care, but if it were not for chiropractic I would still be in pain. A car accident left me with constant lower back pain. I tried everything from painkillers to preparing to have surgery. I heard stories from my friends who had surgery and to this day wish they never had it. So I decided to go to a chiropractor before the surgery and I am so thankful that I did. My back pains are gone and I am living my life to the fullest and pain free.

Jeffrey Harris
Patient Intake Forms Print E-mail

Click icon below to download our new patient forms as a PDF document. Once downloaded, print, fillout, and bring with you to your next office visit.

New Patients:

Please fill out the Application for Treatment forms, the HIPPA form, Medication List, and one or both of the Oswestrys, or the DASH form depending on the areas of your complaint.  

pdf Application for Treatment

pdf Application for Treatment p2

pdf HIPPA form

pdf Medication List

Low back complaints:
pdf Oswestry Low Back Pain Scale

Neck complaints:
pdf Oswestry_Neck_Disability 28/06/2010,17:10 18.41 Kb 

Shoulder, Arm, and Hand complaints:

pdf DASH 49.48 Kb

Returning Patients:

Please fill out the Case History and one of the Oswestrys or the DASH forms.

pdf Case History

Nutritional/Wellness Counseling Patients:

pdf NRT Patient Intake Form

pdf Daily_Food_Record 65.24 Kb

pdf Symptom_Survey 20.22 Kb

pdf Toxicity_Questionnaire 65.50 Kb

pdf Barnes_Thyroid_Temperture_Test 122.11 Kb






United Healthcare New and Returning Patients:

UHC New Patients: Application for Treatment 1&2, HIPPA,Medication List, LEFS, the "Patient Information" and the "Patient Completes This Section" of the Patient Summary Form, and/or the Neck or Back Index and/or the Arm,Shoulder and Hand sections as they apply to your complaints.

 UHC Returning Patients:last visit more than 1 year --Case History Update, Patient Summary Form (fill out "Patient Information" and "Patient Completes This Section"), LEFS,and Oswestry Neck,Back and or DASH form as they apply to your complaints.

 UHC Returning Patients: last visit less than 1 year:

 Patient Summary Form (fill out the "Patient Information" and the "Patient Completes This Section"), LEFS, Medication List, and Oswestry Neck,Back, or DASH form as they apply to your complaints. 

pdf UHC Patient Summary form 353.74 Kb

pdf LEFS 92.08 Kb

UHC Re-exam Patients:

Please download the UHC Patient Summary Form listed above and fill out the either the Oswestry Back Index, Neck Index, or Disabilities of the Arm, Shoulder and Hand(DASH) sections as they apply to your complaints.


You will need Adobe Reader to view and print this document.

If you do not have Adode Reader click the Icon below to download a free copy.

Intake Forms Office Tour My First Visit Payment Options

Request Appointment Your Feedback Email Doctor
Site Map | Copyright © 2008-09 ChiroBuilt by Doyle Advertising