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)
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.
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
QUALITY of LIFE - FORMS
DUTIES UNDER DISTRESS
Loss of Enjoyment
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)