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Forms for Geipel Chiropractic & Holistic Health Care
The following forms are available to be downloaded to your computer and printed using Adobe Acrobat.
By printing and filling out one or more of these forms before you visit
the office will save time and allow you to fill them out completely.
Please do not date the bottom of the forms until the day of your appointment.
Application for Treatment
Used for physical conditions such as back pain, neck pain, extremity pain, headaches, etc.
Basic form for chiropractic conditions. Please fill out completely. Please list the most
current date your condition began in the second question under symptoms. For instance:
what day caused you to have enough discomfort to call for an appointment, when was the
most recent date which you experienced your symptoms.
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Application for Treatment form
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Update Reactivate under 1 year
Used for patients who have not been in our office for one month but not more that 1 year.
Used for physical conditions such as back pain, neck pain, extremity pain, headaches, etc.
Basic form for previous patients not seen within one month but less than 1 year.
Please fill out completely. Please list the most current date your condition began.
For instance: what day caused you to have enough discomfort to call for an appointment,
when was the most recent date which you experienced your symptoms.
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Update Reactivate under 1 year form
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Symptom Survey (Nutritec Symptom Survey)
Used for all patients for nutritional evaluations. Also given prior to Acoustic Cardio
Graph (ACG) readings to coincide with the readings from ACG. Please fill out top
information completely excluding blood pressure readings, pH reading, and pulse. Only
answer the areas which apply to you. If the symptom is something you DO NOT
EXPERIENCE, please leave blank. For mild symptoms such as experiencing the
symptom once or twice in the last 6 months mark the first circle. Moderate symptoms are
symptoms which you experience once or twice in the last month. Severe symptoms are
symptoms which are chronic and you experience them once or twice in a week. If unsure
about a symptom because you avoid things to keep you from experiencing it then this is a
severe symptom. For example, if you avoid a certain food because you know it will upset
your stomach then you will mark it as a severe symptom. You may fax this form to our
office at (630) 378-9963 prior to your appointment. Please make sure name is on all
sheets being faxed and circles are marked clearly. (Using a black permanent marker on
this form when faxing works well.)
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Nutritec Software Symptom Survey form
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Geipel Chiropractic Mission Statement
To help as many people as possible get well and improve their life and health with
holistic methods while maintaining a balance of life. Also, to educate patients
regarding their health so they in turn enlighten others.
Luke 4:40 “Now when the sun was setting, all they that had any sick with divers diseases
brought them unto him; and he laid his hands on every one of them, and healed them.”
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