New Patient Intake Form

Thank you for taking the time to complete this form as fully and accurately as possible. Even questions that may not seem directly related to your main concern help us better understand you as a whole person. This information allows our doctors to prepare for your visit with intention and create a thoughtful, personalized care plan tailored to your unique needs.
New Patient Intake Form (Adult)

Holistic Health Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date Of Birth*

MonthDayYear
Date
MaleFemale
Chief Complaints
Fatigue / Low EnergyDigestive IssuesBrain Fog / Cognitive IssuesSleep problemsChronic PainAcute PainNeck PainLow Back PainMid-Back PainShoulder PainHip PainKnee PainFoot PainCarpal Tunnel SyndromeHormonal ImbalancesWeight ManagementAnxietyDepressionAutoimmune issuesNeurological SymptomsChronic or Recurring InfectionsHeadachesOther
Please describe your other health concerns
What do you believe is wrong with you? *
YesNo
NoYes
what have you found that makes your symptoms better?
NoYes
What have you noticed that makes your symptoms worse?
How would you rate the negative impact of your health concerns on your daily life?*

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1 is No impact, 10 is Severe impact
What are your top health goals? What would success look like to you? *
Example: have enough energy to exercise three times per week, eliminate afternoon energy crashes, improve focus at work....
Medical History
YesNo
Please list all medications and supplements*
Example: levothyroxine 50mcg daily, Magnesium 400mg at bedtime
YesNo
Please list your diagnosed conditions and the approximate time of diagnosis*
List any surgeries you have had, with approximate dates and outcomes.
YesNo
If yes, please describe.
If you have ever been seriously injured, please describe below.
Heart DiseaseDiabetesCancerAutoimmune DiseaseDementiaMental Health ConditionsThyroid ConditionParkinson's DiseaseNone of theseOther
Systems Review
Rate your digestive function*

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1 is Severe Daily Problems, 10 is Excellent. No issues
BloatingGasConstipationDiarrheaReflux / HeartburnAbdominal PainFood SensitivitiesNauseaExtended feeling of fullness even hours after a mealItching around rectumIncreasing frequency of food reactionsAches / Pains in your body after eating certain foodsBloating / Distention after eating
NeverOnce in a while but not oftenFairly oftenAll of the time
YesNo
YesNo
YesNo
Crave sweets during the dayIrritable if meals are missed or delayedDepend on coffee to keep going or get startedGet light headed if meals are missedEating relieves fatigueFeel shaky / jittery if meals are missedFatigue after mealsMust have sweets after mealsDifficulty losing weight
Cannot fall asleepCannot stay asleepSlow starter in the morningCrave saltAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nailsWeight gain when under stressFeel cold - hands, feet, all overRequire excessive amount of sleep to function properlyMental sluggishness
Rate your energy level throughout the day*

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1 is Constantly exhausted, 10 is Excellent, sustained energy
Morning (hard to wake up)Mid-morning crashAfter lunch (2-3pm)EveningAll day
Sleep Quality: How well do you sleep? *

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1 is Terrible, barely sleep, 10 is Excellent, deep restful sleep
Cognitive function: rate your mental clarity and ability to focus. *

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1 is Severe brain fog, 10 is Sharp and clear
Mood and Stress: how would you rate your stress level and emotional well being? *

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1 is Calm and Balanced, 10 is Severe anxiety / depression
Pain and Inflammation: do you experience chronic pain and inflammation? *

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1 is No pain, 10 is Severe daily pain
Memory issuesWord finding difficultyTremorsBalance problemsNumbness / TinglingStinging / Burning in hands or feetCoordination issuesVisual disturbancesHeadachesSeizuresNone of the above
YesNo
Please describe the condition and who was diagnosed.
Lifestyle
Standard American Diet (lots of processed foods, very little fruit & vegetable)Low CarbKetogenic dietPaleo DietLow fat dietVeganVegetarianMediterranean DietOther
Rarely / never1-2 times per week3-4 times per week5+ times per week
If you do exercise, please describe the type of exercise you engage in
Example: walking / running / cycling / strength training
Sleep duration: how many hours per night on average do you sleep? *
How would you rate your overall stress level? *

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1 is Very low stress, 10 is Extremely high stress
Previous Care
YesNo
Standard blood tests (CBC, CMP, Thyroid, Lipid panel, A1c)Hormone testingFood intolerance testingGut health testing (stool analysis)Autoimmune testingOther
If you have had any lab work done, please upload here:

Cancelof
YesNo
What type of treatment did you receive. What worked well (if anything)?
YesNo
What type of protocol were you given? What worked well (if anything)?
Examples: dietary change, lifestyle changes, supplements, therapies
Additional Information
Is there anything else you would like the doctor to know about your health situation?
How would you rate your level of motivation to do whatever is required to resolve your current health issues? Are you willing to make dietary / lifestyle changes if necessary (versus simply passive treatment in the clinic)? *

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1 is Not motivated at all, 10 is Very highly motivated!
Is there someone we can thank for referring you to our clinic? If not, how did you hear about us? *
Dr. WildingDr. MuhrDr. KinsleyI don't have any preference
Chiropractic adjustmentsLaser therapyWhole body photobiomodulation therapyShockwave therapyNutrition / Functional Medicine ServicesI'm not sure. Whatever makes me better!
Office Policy

Thank you for choosing Chiropractic Advantage for your health care needs. We are committed to providing you with exceptional care and service. To ensure we can serve you and all our patients effectively, we've outlined our office policies below.

Payment Policy

We operate on a simple, straightforward payment model. Payment is due in full at the time of service, which allows us to keep our fees competitive and focus on your care rather than insurance paperwork. We accept cash, checks, and credit/debit cards.
Please note that we do not accept payment on lien for personal injury or worker's compensation cases.

Health Insurance

Many health insurance policies now cover alternative health care. However, we've found that a significant number of plans have co-pays that exceed our fees. For this reason, we do not submit claims directly to insurance companies. You are welcome to file for reimbursement on your own, though we cannot guarantee what your insurance will cover.

Respecting Everyone's Time

Our goal is to provide quality, timely care to every patient. When you schedule an appointment, you're reserving dedicated time with our providers-time that becomes unavailable to other patients who may need care. We deeply appreciate your consideration in helping us serve everyone effectively.

Appointment Reminders and Confirmation

We'll send you text and email reminders about your upcoming appointments. To help us manage our schedule efficiently, we ask that you confirm your appointment through our text reminder system or by calling our office. Any unconfirmed appointments will be automatically released back into our schedule at 6 PM the day before, making that time available to other patients. Same-day appointments are automatically confirmed.

If You Need to Cancel or Reschedule

We understand that life happens! If you need to cancel or reschedule, we simply ask that you let us know by 5 PM on the day before your appointment. This advance notice allows us to offer your appointment time to another patient who may be waiting for care.

To cancel or reschedule:
- Reply to your appointment confirmation text, or
- Call our office during business hours:
Monday-Thursday: 8 AM-6 PM
Friday: 8 AM-12 PM

Late Cancellations and Missed Appointments

To help us maintain appointment availability for all patients, we have a $50 fee for cancellations made after 5 PM the day before your appointment, or for missed appointments without notification. For new patients, a late cancellation or no-show for your first appointment will result in the full new patient fee.

We truly appreciate your partnership in helping us provide excellent care to our entire patient community.

I have read and understand the office policies outlined above. The information I have provided is accurate to the best of my knowledge.

Print Name: Your print name
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Patient Intake Form (Adult)

Chief Complaints

Medical History

Systems Review

Lifestyle

Previous Care

Additional Information