Step 1 of 5 — About You
Step 1 of 5

About You

Let's start with the basics so we can get you set up.

Personal Information
Address
Additional Info
Step 2 of 5

What Brings You In?

Tell us about what you're experiencing. You can list up to 4 concerns.

Primary Concern
0 — No pain10 — Unbearable
Pain Quality
Second Concern Optional
0 — No pain10 — Unbearable
How Your Condition Affects You
Mark Areas of Concern

Tap or click where you feel pain or symptoms

FRONT BACK

Step 3 of 5

Health History

Check anything that applies to you, past or present.

Conditions — Check All That Apply
Medications & Past Care
Injuries & Surgeries
Family History
Step 4 of 5

Your Whole Health Picture

This helps Dr. Gray understand you beyond just your symptoms. Take your time — there are no right or wrong answers.

Lifestyle & Wellness
Poor / RestlessDeep / Restorative
Very low stressExtreme stress
SedentaryVery active
Low / FatiguedHigh / Vibrant
StrugglingThriving
Step 5 of 5

Consent & Signature

Please read and sign below to complete your intake.

Informed Consent for Chiropractic Care
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You're All Set!

Thank you for completing your intake form. Dr. Gray will review it before your visit.

We look forward to meeting you. If you have any questions before your appointment, call us at 760-428-2084.