Complete the appropriate Intake Form and the appropriate forms below for Motor Vehicle Accident Injuries, Work Injuries or other Personal Injuries.
New Patient Intake Forms
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Adult New Patient Intake Form
(Adults and Children Age 8+) |
Pediatric New Patient Intake Form
(Babies and Children to Age 7) |
Minor Consent Form (18 and under)
Fill out this consent form if you intend to have your minor child examined or treated without you present.
Fill out this consent form if you intend to have your minor child examined or treated without you present.
Motor Vehicle Accident or Personal Injury Forms
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Motor Vehicle Accident Details Form
Please complete form to provide us with details about your accident. Medical Records Release Form
Please complete this form if you were treated by another doctor and would like your records sent to us for review. |
Accident Claim Information Form
Please complete form to provide details about your claim. Personal Injury Financial Agreement
Please complete this form regarding your financial agreement with JayMac Chiropractic for your personal injury treatment. |
Work Injury Forms
Arizona Worker's Compensation Form
Please complete the top portion of this form if you were injured while working and have an open Worker's Comp claim with your employer.
Please complete the top portion of this form if you were injured while working and have an open Worker's Comp claim with your employer.
Outcome Assessment Tools
The following forms are used by insurance companies to asses pain, dysfunction, and disability. Please select the appropriate form(s) for your injuries.
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Neck Pain Disability Index
Please complete this form if you have neck pain. Headache Disability Index
Please complete this form if you have headaches. Upper Extremity Functional Index (UEFI)
Please complete this form if you have issues in the upper extremities. Shoulder Pain and Disability Index (SPADI)
Please complete this form if you have issues in the shoulder(s). Carpal Tunnel Syndrome Questionnaire
Please complete this form if you have issues with carpal tunnel pain. |
Oswestry Low Back Pain Disability Index
Please complete this form if you have low back pain. TMJ Disability Index
Please complete this form if you have TMJ pain. Lower Extremity Functional Scale (LEFS)
Please complete this form if you have issues in the lower extremities. Knee/Patello-Femoral Questionnaire
Please complete this form if you have knee pain. Visual Analog Scale for Pain/Discomfort
Please complete this form to rate your pain levels. Disregard if you are completing an Intake Form above. |
In order to view the above files please download Adobe Acrobat Reader or equivalent PDF Reader.
