(331) 249-3999

New Lenox

(815) 717-8355


(224) 655-6555

Integrated Physical Medicine

Online Forms

Integrated Physical Medicine 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.

New Patient Intake Form

New Patient Health Questionnaire

Massage Intake Form

Body Contouring Intake Form

Workman’s Comp Form

Automobile Accident Form

Before & After Treatment

Patient Pain Assessment Forms

Back Pain - Upper and lower back pain

Back Pain (United Healthcare Policies) - United Healthcare requires its own unique forms

Neck Pain - Pain above the shoulders and below the head

Neck Pain (United Healthcare Policies) - United Healthcare requires its own unique forms 

Headache/Migraines - (HDI)

Shoulder/Elbow/Wrist/Hand Pain - (DASH)

Knee/Ankle Pain - (LEFS)

Humana Insurance Policies - (PSFS)

Cigna (ASHLink) Policies - Initial Health Assessment Form 

This lets us know the history and current state of your health.  What questions, concerns, goals, regarding wellness can we help you with?  Please tell us!

Download the Free AdobeReader®

Our physicians serve New Lenox, Mokena, Frankfort, Manhattan, Tinley Park, Orland Park, Joliet, Plainfield, Shorewood, Crest Hill, Roselle, Bloomingdale, Schaumburg, Medinah, Hanover Park, Wood Dale, Itasca, and Keeneyville, Naperville, Warrenville, Aurora, Wheaton, Lisle, Eola, Winfield, West Chicago, North Aurora, Batavia and other surrounding cities.