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
🌄

Thank You!

Thank you for completing your intake. We'll be in touch within 24 hours to welcome you to the practice.

Ready to get started? Book your first visit below — most new patients find a time within the next few days.

Next Step
Book Your First Appointment

Wed–Fri 9am–6pm · Saturday 9am–12pm. If you're having trouble finding a convenient time, call or text 760-428-2084 and we'll do our best to fit you in sooner.

Prefer to call? 760-428-2084