Online Forms

Evans Chiropractic & Pain 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.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

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!

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


Medication History - Required

This will the us know your current and former medication history.

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


Member Wellness Registration Form - Optional to receive at home care instructions 

This form can be filled out to register for access to the member wellness section of our website. This will allow us to send you specific treatment instructions for home. You can print it out and bring it in to our office or Click Here to register online! 

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



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Special Offer

New patients receive a $39.00 consultation and examination - $150.00 value!                   (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.

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