Forms & Questionnaires

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Forms can be found here.

New Pediatric patients

If you are representing a new pediatric patient (under 10 years old), please complete the Pediatric Intake form.

New Adult patients

If you are a new adult patient, please complete the Adult Intake form.

New Motor Vehicle Accident patients

If you are a new motor vehicle accident patient, please download the Motor Vehicle Accident Form. Print, complete, and bring with you to your appointment.

New injury questionnaire

If you have a new injury or ailment—or if it has been more than three months since your last visit—please complete the New injury/3+ Month Follow-up form.

Pain questionnaires

If you have pain from the chest up, please complete the Neck Pain questionnaire.

If you have pain from the chest down, please complete the Back Pain questionnaire.

If you have pain in your extremities, please complete the appropriate Upper or Lower Extremity questionnaire.

Wellness planning

If you are interested in issues that may be related to low energy/fatigue, metabolism, nutrition, gut/digestion issues, please refer to the evaluation documents:

Please download, print, and complete prior to your consultation with your Back In Line doctor.

Iowa High School Athletic Association (IHSAA)

If your child is in need of a physical prior to playing High School sports, you must provide your school a completed IHSAA Pre-Participation Physical Examination Form completed by your Back In Line doctor.

According to the IHSAA: “Every year each student (grades 7-12) shall present to the student’s superintendent a certificate signed by a licensed physician and surgeon, osteopathic physician and surgeon, osteopath, qualified doctor of chiropractic, licensed physician assistant, or advanced registered nurse practitioner, to the effect that the student has been examined and may safely engage in athletic competition. This certificate of physical examination is valid for the purposes of this rule for one (1) calendar year. A grace period, not to exceed thirty (30) days, is allowed for expired certifications of physical examination.”

Additional notices

Possible additional paperwork

​If you have an appointment for a non-musculoskeletal condition (tummy aches, hormone issues, adrenal concerns, thyroid, and anything “functional medicine” related)  you will have additional paperwork to fill out at our office. We apologize for the inconvenience.

24 hour cancellation policy

Back In Line Family Chiropractic & Wellness enforces a 24 hour cancellation policy for all appointments. In order to reschedule your appointment you must notify a Back In Line Team Member at 319-892-3363 as soon as possible to avoid being charged for the missed appointment.  By calling in ahead (because you are feeling better, or because something came up) you allow for us to reschedule another patient in that spot. Thank you for accommodating this request.