Online Forms

Leaf Chiropractic A Creating Wellness Center offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

TRY OUR NEW ONLINE FORMS!  No printing required! 

Click here to access our online forms!

If you would still like to print your new patient intake forms continue below.

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Download the necessary form(s), print it out and fill in the required information.
• Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form  

Neck Index Questionairre 

Low Back Index Questionairre

Pediatric Health History Form

Personal Injury/Auto Accident Forms (Required if you have recently been in an auto accident)

These forms are required to let us get a better idea of the severity of your recent automobile accident.  Also, please fill out either the neck, generalized back, or low back pain based on what type of pain you are experiencing.

Initial Personal Injury Paperwork (required)

Auto Accident Description (required)

Doctor's Lien (required)

 Worker's Compensation Paperwork (Required if you have recently been in a work related accident)

If you have been in a recent work injury, and you have not reported this either your employer, or any other medical provider, please complete the form below.  This will give us an accurate description of your work injury, and help us determine the necessary treatment protocol.

First Report of Injury (FROI) paperwork (Fill out only the injured worker and injury information)

 Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form

Scoliosis Screening Form

This form is required to have your child screened for scoliosis.  One form is required for EACH child.  Also attached is a word document describing scoliosis, and why is it vital to have your child screened for scoliosis every year.  Microsoft Word is required to access forms.

Download Scoliosis Screening Form (Required)

Download Scoliosis Information Sheet (Optional)

Standard Process Forms (Nutritional patients)

These forms are used to assist your doctor in determining if you would benefit from a purification program, or if you would benifit from generalized supplementation.  Print these forms, fill them out, then return them to our office for your doctor to evaluate them.

Download Symptom Survey Form

Download Toxicity Questionnaire

Download Daily Record of Food Intake Form