Chiropractic Forms

New patient forms

Prior to arriving for your appointment, complete the new patient forms and bring them with you. You may be asked to complete additional forms when you arrive. If you are unsure of how to answer, check with the front desk staff.

Instructions

Neck Index – fill out only if you are seeking treatment for a neck issue
Back Index – fill out only if you are seeking treatment for a back issue
Patient Health Questionnaire (PHQ) - all patients fill out the PHQ

NOTE: If you are not seeking treatment for a neck or back issue, skip the “Neck Index” and “Back Index” but fill out
the Patient Health Questionnaire (PHQ).

• New Chiropractic Patient - ADULT (pdf)
• New Chiropractic Patient - PEDIATRIC (pdf)

Readmit patient forms

Prior to arriving for your readmit appointment, complete the readmit patient forms and bring them with you. You may be asked to complete additional forms when you arrive. If you are unsure of how to answer, check with the front desk staff.

• Readmit Chiropractic Patient - ADULT (pdf)
• Readmit Chiropractic Patient - PEDIATRIC (pdf)

Auto or work injury forms

If you have an auto or work injury, report it to your insurance company or employer prior to contacting the clinic.

• Auto Injury (pdf)
• Work Injury (pdf)

For questions, contact:

Bloomington Natural Care Center
bncc@nwhealth.edu
952-886-7588