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Online Forms

Geipel Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to 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.

Download & Print Form

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.

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.

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Office Hours

Our Regular Schedule

Geipel Chiropractic

Monday:

7:50am - 12pm

2:00pm - 5:30pm

Tuesday:

Closed

Closed

Wednesday:

7:50am - 12pm

2:30pm - 5:50pm

Thursday:

7:50am - 12pm

Closed

Friday:

7:50am - 12pm

2:00pm - 5:50pm

Saturday:

7:50am - 12pm

Closed

Sunday:

Closed

Closed

Location

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