Worker's Compensation Patients
Gardiner Family Chiropractic offers our patient forms online so you can complete them in the convenience of your own home or office.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Print out all forms below and fill in the required information. We ask that you complete the forms as close to your appointment time as possible so that your doctor may have the most current information regarding your condition.
- Bring your completed forms with you to your appointment along with your driver's license and any insurance cards.
Registration Form - Required for all patients
Personal information about yourself. It must be filled out completely and must be signed and dated so that we may bill your insurance company directly.
Complaint Form - Required for all patients
This is the form that tells us about your specific complaints. It must be filled out completely. List each complaint separately and in the order of severity with the complaint that is most severe listed as the chief complaint. For example if you have lower back pain, neck pain, and foot pain these are three separate complaints. The one that is bothering you the most should be listed as the chief complaint.
We provide room for three complaints on side 1, if you have more than three complaints, feel free to use multiple copies of side 1. Please be sure to circle one number for "Intensity of your pain" and check off one percentage for "How much time is this complaint present?" for each complaint.
Be sure to print and complete side 2 as well. This side must be signed and dated.
Health History - Required for all patients
This form tells us about your health history, activity, and family health history. It helps your doctor get a complete picture of your overall health. This is a two-sided form. Be sure to print and complete both sides. Side 2 must be signed and dated.
Low Back Pain and Disability Questionnaire - Required for all patients with low back and/or leg complaints
Choose the closest answer (one answer only per question) to how you are feeling right now (not at your worst or best) regarding your low back and/or leg complaints. If a question is not applicable, choose the '0' answer.
Low Back Pain and Disability Questionnaire
Neck Pain and Disability Questionnaire - Required for all patients with neck and/or arm complaints and/or headaches
Choose the closest answer (one answer only per question) to how you are feeling right now (not at your worst or best) regarding your neck and/or arm complaints and/or headaches. If a question is not applicable, choose the '0' answer.
Neck Pain and Disability Questionnaire
Notice of Privacy Practices - Required for all patients
This form explains our policies and your rights regarding our disclosure of your Protected Health Information. This form must be signed and dated before a file for you can be started in our office.
Additional Forms Required for Worker's Compensation Patients
The following additional forms are required to be filled out and signed where appropriate by all Worker's Compensation Patients.
Physical Capacities Questionnaire
Worker's Compensation Patient History
Medical Reports and Doctor's Lien
Permission for Attorney to Share Information - coming soon
Worker's Compensation Patients Under the Age of 18
The following form must be completed by the minor's parent/legal guardian before the patient may be seen in our office.
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