Print Forms

Lipkin Chiropractic Clinic offers our patient forms to print and fill in the convenience of your home before you arrive to our office. 

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Print the necessary form(s), Complete and DATE for the Date of your appointment.
  • Bring your printed and completed form(s) to your appointment.

INITIAL VISIT Health History Form

For a New Patient (or existing patients last seen over 3 years from last visit)  

Print New Patient / Initial Visit Form 



RE-EXAMINATION - Follow-up Questionnaire (for re-exams to check progress)

Print Re-Exam Form


NECK  INDEX

Print Neck Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your NECK condition affects this activity.  

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of NECK pain.


BACK  INDEX

Print Back Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your BACK condition affects this activity.

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of BACK pain.



ACUPUNCTURE - Intake Form

Print Acupuncture Form



PRE-PARTICIPATION SCHOOL PHYSICALS  

$20 all day, everyday

Print School Physical  (EL2) Form

Please fill out Page 1 and the top of Page 2 prior to examination

Pinellas County Middle School and High School Athletic Programs

FHSAA Pre-participation Physical Evaluation Form EL2 (rev.5/14)

 V70.3 ICD-9-CM


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CONTACT US TODAY

We look forward to hearing from you

Location

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Office Hours

Our Regular Schedule

Monday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Tuesday:

Call for Appt

2:45 pm - 6:00 pm

Wednesday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Thursday:

By Appointment

By Appointment

Friday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Saturday:

By Appointment

Closed

Sunday:

Closed

Closed