Online Forms

Lemont Active Chiro 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.

• Download the necessary forms, print them out and fill in the required information.
• Fax (630.257.0550) or email ([email protected]) your completed forms, or bring them with you to your appointment.

1. Chiropractic Registration Form (2 pages) - Required

Download & Print Form

2. New Patient Intake Form (2 pages) - Required

Please complete one intake form for EACH area of complaint.

Download & Print Form

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Please complete any of the following that apply. (EACH form should correspond with an intake form #2.) - Required

3a. Back Pain Questionnaire

Download & Print Form

3b. Neck Pain Questionnaire

Download & Print Form

3c. Upper Extremity Functionality Index

Download & Print Form

3d. Lower Extremity Functionality Scale

Download & Print Form

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4. Personal Injury - Motor Vehicle Accident Intake Form

Download & Print Form

5. Work Comp New Patient Intake Form

Download & Print Form

6. Headache Disability Index

Download & Print Form

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