Forms & Instructions

For our patients at Integrated Physical Medicine

Let’s speed things up

Integrated Physical Medicine offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office. These let us know about the history and current state of your health.

Download the necessary forms, print them out and fill in the required information. Then fax us your printed and completed form(s) or bring it with you to your appointment.

INTAKE FORMS

New Patient - Intake Form

New Patient - Health Questionnaire

Massage - Intake Form

Body Contouring - Intake Form

Body Contouring - Consent Form

Automobile Accident Questionnaire

PAIN ASSESSMENT FORMS

Oswestry Low Back Pain Disability Questionnaire

Headache Disability Index Questionnaire

Neck Pain Disability Index Questionnaire

Disabilities of the Arms, Shoulder & Hand (DASH)

Lower Extremity Functional Scale (LEFS)

Some insurance companies require their own unique forms.

Back Index - United Healthcare

Neck Index - United Healthcare

Patient Specific Functional Scale (PSFS) - Humana

Initial Health Status - Cigna

INSTRUCTIONS

Body Contouring - Instructions

Platelet Rich Plasma - After Care Instructions

Platelet Rich Plasma - Pre-Procedure Instructions

Human Cellular Tissue Products - Instructions

Trigger Point Therapy - Post Procedure Instructions

Jessica Kwilosz

Director of Front Desk Operations

Questions?

What questions, concerns and goals regarding wellness can we help you with? Please tell us! All of our offices have someone available to talk with during regular business hours.

Make an Appointment

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Forms & Instructions

Let’s speed things up

INTAKE FORMS

PAIN ASSESSMENT FORMS

INSTRUCTIONS

Jessica Kwilosz

Questions?

Joliet

Naperville

New Lenox

Roselle

Make an Appointment