Patient Intake Forms
Would you like to save yourself 20 minutes during your first visit to our office? The following forms are available online for your convenience.
*NEW* Our intake form is in a writable PDF format, on it you will see blue highlighted areas upon which you simply have to click and type in your response or click on the □ and that will place an X in the box you wish to respond to.
Upon completing this intake form please print it out and sign it and bring it with you to your initial appointment, the information you provide us on this form in will speed up your office visit and allow us to better serve your healthcare needs.
| GENERAL INTAKE FORMS |
| - Please click on the following link: INITIAL INTAKE FORM |
For best results, download this file to your computer first and then fill it out. Upon completion, your computer will prompt you to save it again and this way you are assured to save all the information provided on the form. You have the option of printing it yourself or emailing your completed intake form to our office at lifeinmotionchiro@yahoo.com. |
| PAIN QUESTIONNAIRE FORMS |
Please fill out ONLY the form or forms that apply to you. The purpose of these outcome assessment tools is to determine YOUR perceived FUNCTIONAL ABILITY prior to starting treatment. They are then utilized again after an initial trial of treatment to determine YOUR perceived functional ability to assess whether the management strategy being employed is making a relevant difference in YOUR ability to conduct and ENJOY LIFE. When filled out ahead of time, this will save you an additional 5 minutes during your first visit. |
| Is your Chief Complaint neck pain? Please click the following link: |
| NECK PAIN QUESTIONNAIRE |
| Is your Chief Complaint back pain? Please click the following link: |
| BACK PAIN QUESTIONNAIRE |
| Is your Chief Complaint headache pain? Please click the following link: |
| HEADACHE DISABILITY QUESTIONNAIRE |
| Experiencing arm, shoulder, or hand pain? Please click the following link: |
| DASH QUESTIONNAIRE |
| PRENATAL INTAKE FORMS |
| - Please click on the following link: PRENATAL INTAKE FORM |
| The file contains the following forms: same as described above as well as specific questions about your pregnancy. |
