Inner Balance Chiropractic
114 E Oak St
Fort Collins, CO 80524

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Personal Health History

Family/Primary Physician

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Personal Incident History:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


For Women Only


Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Were You Aware That...

Health Problems & Concerns:

Please select all that you have had or currently have.


When someone seeks chiropractic health care, and when a chiropractor accepts someone for such care, it is essential that both are seeking and working for the same goals. Chiropractic does NOT diagnose or treat disease. Chiropractic only has one goal: to locate, analyze, and correct vertebral subluxation to the nervous system. The purpose of the nervous system is to control and coordinate all bodily function. Interference to this master system produces improper function of the body. The subluxation (spinal misalignment causing nerve interference), in and of itself, is a detriment to life and health. Correction of the subluxation through a specific chiropractic adjustment allows the body to function at its optimum level. This allows the innate healing power of the body to work at maximum efficiency to restore, maintain, and promote natural health. The appointments that you and Dr. Curtis schedule are an investment in your health. You will have his undivided time and attention, therefore it is vital that when you make an appointment you show up and are on time. Out of respect to your health, our office, and other practice members, missed appointments will be charged our normal fee.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


Finalizing Form

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