new patients welcome Bolingbrook, IL
Here at Geipel Chiropractic, we value our patients. We acknowledge that going to a new place for the first time can be nerve racking. We want to do everything we can to eliminate any unnecessary stressors, which is why we include the option of printing and completing your forms at home. We think of our patients as part of our extended family, and we are excited to meet you!

If you have any questions regarding your first visit, please don’t hesitate to call us at (630) 378-4100.

Patient Forms

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.

Download & Print Form

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.)

Download & Print Form

Patient Health History
In order to provide you with holistic care and address the root cause of your health concerns, we would like you to complete a detailed and comprehensive health questionnaire. Your answers will help you achieve better treatment results. The more you are willing to share with us, the better we can treat the root cause of your health conditions and symptoms.

Download & Print Form

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