Please check the web address above for "https", ensuring the security of your personal information. If not, go to Patient Forms page -> Patient Intake - Natural Life Chiropractic

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Please check the web address above for "https", ensuring the security of your personal information. If not, go to Patient Forms page -> Patient Intake

Patient Forms

When you have completely filled out the intake form, you can print the page before sending the information securely.
You can bring it in to your first appointment as a reference and a backup. Thanks!






 Headaches Shoulder Wrist Foot
 Neck Hand Legs Other
 Upper Back Jaw Hip
 Mid Back Arm Knee
 Low Back Elbow Ankle





 Sharp Shooting w/motion Tingly
 Shooting Stabbing w/motion Pinching
 Stabbing Radiating Burning
 Numb Stiff Achy
 Dull Electric w/motion Other
 Sharp w/motion Diffuse






 No One Massage Therapist Physical Therapist
 Chiropractor ER Physician Primary Care Physician
 Neurologist Orthopedist Other



No IdeaSports InjuryGolf
GraduallySlept WrongYoga
Auto AccidentA FallOther
Work InjuryPoor Posture


Yes
Yes, at times
No

 Always there Running Stress
 Bending Shoveling Snow Travelling
 Driving Sitting Weather Change
 Flexing Sleeping Work
 Extending Stairs Working at a Computer
 Gardening Climbing Working Out
 Golf Standing Up Yard Work
 Painting Lifting Other
 Tennis Standing


 Nothing Lying Face Down Stretching
 Chiropractic Lying On Side Swimming
 Analgesic cream Massage T.E.N.S. Unit
 Bending Forward OTC Meds Walking
 Exercising Prescription Meds Warm Bath
 Heat Muscle Relaxer Orthotics
 Ice Resting Yoga
 Lying On Back/Knees Bent Standing Other


WorkPersonal RelationshipsIt isn't going away
Leisure ActivitiesSleepIt is getting worse
Mental OutlookIt could be seriousOther




 Sharp Shooting w/motion Tingly
 Shooting Stabbing w/motion Pinching
 Stabbing Radiating Burning
 Numb Stiff Achy
 Dull Electric w/motion Other
 Sharp w/motion Diffuse






 No One Massage Therapist Physical Therapist
 Chiropractor ER Physician Primary Care Physician
 Neurologist Orthopedist Other



No IdeaSports InjuryGolf
GraduallySlept WrongYoga
Auto AccidentA FallOther
Work InjuryPoor Posture



 Always there Running Stress
 Bending Shoveling Snow Travelling
 Driving Sitting Weather Change
 Flexing Sleeping Work
 Extending Stairs Working at a Computer
 Gardening Climbing Working Out
 Golf Standing Up Yard Work
 Painting Lifting Other
 Tennis Standing


 Nothing Lying Face Down Stretching
 Chiropractic Lying On Side Swimming
 Analgesic cream Massage T.E.N.S. Unit
 Bending Forward OTC Meds Walking
 Exercising Prescription Meds Warm Bath
 Heat Muscle Relaxer Orthotics
 Ice Resting Yoga
 Lying On Back/Knees Bent Standing Other


WorkPersonal RelationshipsIt isn't going away
Leisure ActivitiesSleepIt is getting worse
Mental OutlookIt could be seriousOther




 Sharp Shooting w/motion Tingly
 Shooting Stabbing w/motion Pinching
 Stabbing Radiating Burning
 Numb Stiff Achy
 Dull Electric w/motion Other
 Sharp w/motion Diffuse






 No One Massage Therapist Physical Therapist
 Chiropractor ER Physician Primary Care Physician
 Neurologist Orthopedist Other



No IdeaSports InjuryGolf
GraduallySlept WrongYoga
Auto AccidentA FallOther
Work InjuryPoor Posture



 Always there Running Stress
 Bending Shoveling Snow Travelling
 Driving Sitting Weather Change
 Flexing Sleeping Work
 Extending Stairs Working at a Computer
 Gardening Climbing Working Out
 Golf Standing Up Yard Work
 Painting Lifting Other
 Tennis Standing


 Nothing Lying Face Down Stretching
 Chiropractic Lying On Side Swimming
 Analgesic cream Massage T.E.N.S. Unit
 Bending Forward OTC Meds Walking
 Exercising Prescription Meds Warm Bath
 Heat Muscle Relaxer Orthotics
 Ice Resting Yoga
 Lying On Back/Knees Bent Standing Other


WorkPersonal RelationshipsIt isn't going away
Leisure ActivitiesSleepIt is getting worse
Mental OutlookIt could be seriousOther








 Rheumatoid Arthritis Cancer
 Diabetes ALS
 Lupus Other
 Heart Problems


 Past
 Present

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 Past
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 Past
 Recent

 Past
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 Past
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 Past
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 Past
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 Past
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 Past
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 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
 Present

 Past
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 Past
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No
Yes


No
Yes


No
Yes




 Nutritional Counseling Hypnotherapy
 Personal Training Psychotherapy
 Massage Nurse Practitioner
 Homeopathy Yoga
 Acupuncture
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