WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]
262-785-5515 H
H

262-785-5515

Online Forms

Evans Chiropractic & Pain Relief Laser Clinic offers our patient form(s) online so they can be completed it in the convenience of your own home or 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.
  • THE NEW PATIENT INTAKE FORM DOES NOT NEED TO BE PRINTED. It is sent to our secure server upon completion. Other forms can be completed at the clinic before your appointment if you are not able to print.

New Patient INTAKE - Health History Form - Required

ALL NEW PATIENTS START HERE.  No need to print this. Complete via the link below. This lets us know the history and current state of your health.

What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Form takes approximately 20 minutes to complete.

Welcome to our group. :) We look forward to helping you feel better.

Click here to fill out our New Patient Intake Form


Patient Consent Form - Required

Download & Print Form


Neck Pain Form- Required

This lets us know the history and current state of your neck health

Download & Print Form


Low Back Pain Form - Required

This lets us know the history and current state of your back health

Download & Print Form


Knee Pain Functional Scale - Required only if applicable

This lets us know the history and current state of your knee health. 

Download & Print Form


Hip Pain Questionnaire - Required only if applicable

This lets us know the history and current state of your hip health.

Download & Print Form


Arm and Hand Questionnaire - Required only if applicable

This lets us know the history and current state of your arm and hand health.

Download & Print Form


Leg and Foot Questionnaire - Required only if application

This lets us know the history and current state of your lower extremity health.

Download & Print Form



TMJ Disability Index - Required only if applicable

This lets us know the history and current state of your health

Download & Print Form


Mental Health Questionnaire - Required only if applicable

This lets us know you current and prior stress level

Download & Print Form



Download the Free AdobeReader�

Special Offer

Limited Time Offer for Spring!
$25 Consultation & Examination

$250 value! (medicare rules apply)! (medicare rules apply)

Sign-up using the form or call us at 262-785-5515 to take advantage of this exclusive offer. You must mention that you saw this on our website. This cannot be combined with other offers. Good toward first visit chiropractic services only.

Office Hours

DayMorningAfternoon
Monday9:00am7:00pm
Tuesday9:00am7:00pm
Wednesday9:00am7:00pm
Thursday9:00am7:00pm
Friday9:00am5:00pm
SaturdayBy Appt
SundayBy Appt
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am 9:00am 9:00am 9:00am 9:00am By Appt By Appt
7:00pm 7:00pm 7:00pm 7:00pm 5:00pm