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New Patient Online Forms

Johnson Chiropractic & Holistic Health Center offers our new chiropractic patient form(s) online so they can be completed in the convenience of your own home or office.

We have three areas from which to choose forms. 

Chiropractic & Acupuncture

Nutritional Consulting / Functional Medicine

Auto Accident

Click the links below to download, print, and fill them out. Don't forget to bring them with you to your first appointment!


Chiropractic & Acupuncture New Patient Forms

1. Adult Intake: Ages 13 and up

2. Pediatric Intake: Birth to 12 years old - Please note this intake form is very comprehensive. If you have any questions regarding the form please let us know.

3. Back Pain Questionnaire - Required if you have BACK PAIN

4. Neck Pain Questionnaire - Required if you have NECK PAIN

5. Headache Questionnaire - Required if you have HEADACHES

If you have Medicare, the following form is required:

Medicare Advance Beneficiary Notice of Non-Coverage (ABN)

If you wish to have your records released for any reason you are required to fill out the form below. This includes release to family, other medical facilities, legal representative, etc.

Records from Johnson Chiropractic to Another Party

Records from another party to Johnson Chiropractic


Nutritional Consulting / Functional Medicine Forms

1. New Patient Functional Medicine Intake & Consent Form

If you wish to have your records released for any reason you are required to fill out the form below. This includes release to family, other medical facilities, legal representative, etc.

Health Records Release Form


Auto Accident Patients

These forms are required if you are seeking treatment due to an automobile accident

The following forms are required for auto injury cases.

1. Auto Injury Intake Form

2. Back Pain Questionnaire - Required if you have BACK PAIN

3. Neck Pain Questionnaire - Required if you have NECK PAIN

4. Headache Questionnaire - Required if you have HEADACHES

5. Health Records Release Form


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