Forms and Questionnaires
Completed forms can be emailed to firstname.lastname@example.org
New Pediatric patients
If you are representing a new pediatric patient, please download the Pediatric Patient Form. Print, complete, and bring with you to your child’s appointment.
New Adult patients
If you are a new adult patient, please download the Adult Patient 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 download the New Injury Questionnaire. Print, complete, and bring with you to your appointment.
Neck pain questionnaire
If you have pain from the chest up, please download the Neck Pain Questionnaire. Print, complete, and bring with you to your appointment.
Back pain questionaire
If you have pain from the chest down, please download, print, and complete the Lower Back Pain Questionnaire. Print, complete, and bring with you to your appointment.
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.”