Please fill out these chiropractic health forms which detail your present and previous health and bring them with you on your first visit. The forms are in .pdf format (Adobe Acrobat). If you prefer, you can wait to fill out your paperwork in our office.

New Patients: Adult Health History
All adult patients, please fill out Adult Health History Form and others as appropriate:

1. Adult Health History Form
2. Functional Rating Index (neck, and back complaints)
3. Upper Limb Functional Index (shoulder, arm, forearm, hand/wrist complaints)
4. Lower Limb Functional Scale (knee, ankle, leg, or foot condition complaints)


New Patients: Infant/Child Health History
 

For children aged 6 or older, please fill out the adult history form above.

For children aged 5 or below please fill out this form:

Pediatric Health History Form


Existing Patients:
Please fill out both of these forms:

1. Reactivation
2. Functional Rating Index
3. Upper Limb Functional Index (shoulder, arm, forearm, hand/wrist complaints)
4. Lower Limb Functional Scale (knee, ankle, leg, or foot condition complaints)


*Patients who have United Healthcare (UHC) as their primary insurance carrier are required to fill out the additional paperwork below before examination or treatment.

Patient Summary Form
If UHC is your primary insurance carrier, you will be required to fill out the “Patient Summary Form” in addition to our Health History form above. United Healthcare patients should also see the Neck and Back Index forms below as well as the DASH and LEFS forms.

Neck Index
If you have UHC insurance and currently suffer from a neck condition, please download and complete this form.

Back Index 
If you UHC insurance and currently suffer from a back condition, please download and complete this form.

Disabilities of the Shoulder, Arm, and Hand Form (DASH) 
If you have UHC insurance and currently suffer from a shoulder, elbow, or hand condition, please download and complete this form.

Lower Extremity Functional Scale Form (LEFS)
If you have UHC insurance and suffer from a knee, ankle, leg, or foot condition, please download and complete this form.


All Patients:
Please click here for our Notice of Privacy Practices (HIPAA)