New Patient Forms for Grand Junction Office

Thank you for taking the time to pre-register for our services.  All our forms are available in PDF format at the bottom of this page. Please let us know if you cannot find a form.

How to fill out our New Patient Forms  (The information as listed below, in a printable form.)

1. The Information Form is rather self-explanatory.  Keep in mind that if the patient is a child, the child's information (Last Name, First Name, and Date of Birth) is to be recorded first.

2. Read through and sign the Detail Care Fee Schedule.

3. Read and sign the Consent to Care Form.

4. Next print and complete the appropriate Health Questionnaire Form as needed 
    For Infants ages birth to 18 months Infant Form
For children ages 18 months to 16 years Child Form
For adults 16 years and up Adult Form

5. The following detail instructions are for the Adult Form questionnaire

The top portion of your Health History Form is rather self-explanatory. Your name, birth date, spouse/kids, etc.

The next part is the issues that brought you here to us. If you don’t have four issues, just put the ones you have. If you have more than four, pick what you think are the four most important issues. If you have no issues and are here just for wellness, there is a small box above the numbers for you to check.

Be sure to be as specific as possible with your issues. On the right side is a place to write how it affects your life. Say, for example, your most important issue is your low back. You would write “Low Back.” Followed by details such as “It stops me from holding my baby,” or “It really hurts when I’m active,” is what we are looking for. Then rate from 1-10 how it affects your life, 1 being “not so bad” and 10 being “I can’t do anything because of this issue.”

Below the lines are descriptions of your pain. The numbers after “Sharp”, “Dull”, “Burning,” etc. correlate to the above issues, so, for example, if #1 was Low Back and it’s a dull, achy pain that comes and goes, you would circle #1 after “Dull,” “Achy,” and “Comes & Goes.” If your second issue was your left knee and it is a throbbing, constant pain, you would circle #2 after “Throbbing” and “Constant.”

Continue along with things you’have tried for your issues, what makes it better, what makes it worse, etc. 

Next we ask about any prescriptions and medications you are currently on.

The bottom part of the page asks for any symptoms you are either currently experiencing, or have experienced in the past. “C” is Current, and “P” is Past. Check any items that pertain to you. There are lines behind each symptom for you to put any details needed, like if you suffer from migraine headaches, you would check “C” by headaches and on the line after, you would write “migraines.” These symptoms continue on to the next page.

On the 2nd page, after you get done with the symptoms, we will look at your daily activities. The doctor is looking for patterns here, and this information is also required for Medicare and other insurances. Check if you have any problems/pain doing any of these daily activities listed.

On the 3rd page, we are looking at your childhood. Answer these questions the best you can. Many of the problems that you experience as an adult had their origin in childhood.

Then we look at the stress you currently have, or have had in your life. C is Child, T is Teen, A is Adult, and N is Never. So, for example, you were in a car accident as a child, and were in another one last week, you would circle “C” and “A” after Car Accident.

The bottom portion of page 3 covers any previous chiropractic care you may or may not have had, accidents/injuries, and your work and play habits. 

The top of page 4 covers your diet and family history. Sign the top portion of the page, and the bottom of the page as indicated in the yellow.

Welcome and Office Information

Information Form

Detail Care Fee Schedule

Consent to Care Form

Consent to Care Form in Spanish




Wellness Membership Program Agreement