Forms & Questionnaires
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:
- Toxicity/Inflammation Questionnaire
- Thyroid Risk Questionnaire
- Hormone Questionnaire
- Adrenal Health Questionnaire
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.”
