Online Forms

We offer online forms and registration to all new patients to make your first visit in our office more comfortable and much shorter. You can now download all necessary forms from this page, fill them out in the privacy of your own home, and bring them in on your first visit or email the completed forms to us prior to your appointment at purposefulpractice@gmail.com.

Please be advised that not all forms are required or covered during the first visit. Following your introductory call, we will advise you of what forms you will need to complete for your next appointment.

If you are a new Functional Medicine patient, you will need to download the Functional Health Assessment Form & Intake as well as the appropriate Nutritional Health Record form below. We will advise you of what additional forms you may need to complete. Please also obtain copies of all recent and past lab results from the past 3 years.

If you are a new Chiropractic patient, you will need to download either The Holistic Chiropractic Intake or The Basic Chiropractic Intake. If you or your child are under the age of 18, there are separate forms based on the age of the patient. For more details, read the descriptions below.

To download, click on the PDF icon to the left of the form header. If you need help, please feel free to contact us!


Functional Health Assessment Form

This is a comprehensive survey that assists our practitioners in connecting your symptoms with the underlying problems. By answering a series of questions covering each major organ and endocrine system, our doctors can assist you in finding the most appropriate steps to follow, whether that be lab testing, nutritional supplements, hands-on healing techniques or lifestyle modifications. This greatly assists us in gathering detailed information of your health story in order to customize our recommendations for you.

Holistic Chiropractic Member Intake

This form is for new patients interested in holistic chiropractic care. The holistic evaluation entails more in depth care and longer in-office visits. Instead of the quick chiropractic adjustment that typically lasts a few minutes, holistic chiropractic patients will receive additional work and treatment in addition to their adjustment, including: stretching / distraction, vibra-care percussion, basic SOT pelvic blocking, cranial work, digestive work and more (as needed). During visits we will frequently discuss related health information and make suggestions of dietary changes, lifestyle adjustments, supplements, supportive therapies and techniques, and more. Please note this is the ADULT form for new practice members age 18 and older.

Basic Chiropractic Member Intake

This form is for new patients interested in basic chiropractic care. The basic chiropractic evaluation allows perspective patients to be established in our office for quick, brief visits for chiropractic adjustments only. These visits are more in alignment with what you will see in most chiropractic offices and allows for those in a hurry or just wanting simple "tune-ups" at an affordable cost. It does not include in depth history or comprehensive care. Please note this is the ADULT form for new practice members age 18 and older.

Medical Release Form

In the case that health information need to be shared among practitioners and providers, it is standard law that a Medical Records Release Form be completed by the patient to either obtain or to share information with another provider / office. If records will be requested and/or shared with/from our office, we require a signed copy of this form to remain on file for compliance purposes.

Pediatric Forms

PEDIATRIC Chiropractic Health Intake

For a focused chiropractic evaluation of your school-aged child (ages 4 through 17), please complete this Pediatric Member Intake Form. If there is additional information, lab results, or paperwork from previous medical treatment that you would like to provide, please obtain copies and be prepared to leave them on file with our office. If your child is also being seen for functional medicine or nutritional consulting, additional forms will need to be completed for the complete evaluation.

NEWBORN-TODDLER Chiropractic Health Intake

For a focused chiropractic evaluation of your baby (newborn to toddlers under the age of 4 years old), please complete the Newborn-Toddler Member Intake Form. If there is additional information, lab results, or paperwork from previous medical treatment that you would like to provide, please obtain copies and be prepared to leave them on file with our office. If your child is also being seen for functional medicine or nutritional consulting, additional forms will need to be completed for the complete evaluation.

PEDIATRIC Nutrition Health Record

Any child being seen in our office for functional medicine or nutritional consulting will need to complete the Pediatric Nutritional Health Record form prior to your scheduled appointment. If there is additional information, lab results, or paperwork from previous medical treatment that you would like to provide, please obtain copies and be prepared to leave them on file with our office. It is ideal to email or return the form prior to your appointment but may also be returned at the time of your first appointment.

Women's Care

Women's Nutritional Health Record

Any woman being seen in our office for functional medicine or nutritional consulting will need to complete the Women's Nutritional Health Record form prior to your scheduled appointment. If there is additional information, lab results, or paperwork from previous medical treatment that you would like to provide, please obtain copies and be prepared to leave them on file with our office. It is ideal to email or return the form prior to your appointment but may also be returned at the time of your first appointment.

Hormone Charting Survey

This is a 30-day chart to evaluate hormone dysfunction and and best interpret symptoms related to hormone imbalances. More complete testing and evaluation is available through saliva or serum samples if necessary through one of our outside lab partners. This can assist our practitioners in targeting hormone issues and also allows you to become more aware of your symptoms and fluctuations over a 30-day period.

Prenatal Health Record

This form is for new or established practice members that are pregnant. We will often have you complete additional forms depending on your level care, but this basic Prenatal Form is required for any patients that will be under care in our facility during their pregnancy.

Men's Care

Men's Nutritional Health Record

Any man being seen in our office for functional medicine or nutritional consulting will need to complete the Men's Nutritional Health Record form prior to your scheduled appointment. If there is additional information, lab results, or paperwork from previous medical treatment that you would like to provide, please obtain copies and be prepared to leave them on file with our office. It is ideal to email or return the form prior to your appointment but may also be returned at the time of your first appointment.

Additional Questionnaires

Life Stress Questionnaire

The Life Stress Questionnaire is a tool we use to allow our practitioners a glimpse into your current state of stress and what major stressful events have happened to you (and when). This is a useful tool when laying out your health story timeline in order to connect the web of your health and your life. This can be used throughout treatment to monitor the impact stress is having on your health.

Adrenal Function Questionnaire

Stress in life is inevitable. How we adapt to the stress we are under is the key. The adrenal glands, part of the endocrine system, are responsible for the messages that are sent throughout the body in the form of hormones. Determining the state of their function through this preliminary questionnaire can guide our practitioners along your healing journey and help determine if further testing is necessary or to track the success of treatment in cases of adrenal dysfunction.

Toxin Exposure Questionnaire

Exposure to toxins is also inevitable in our world today. However, we can minimize our exposure by eliminating or reducing known sources wherever possible. It is shocking to discover all the places that toxins can creep into your life and how much they can impact your health. This questionnaire allows us to target where unsafe exposures may be coming from and to open the discussion of further testing and next steps, if necessary.

Liver Function Questionnaire

While avoidance to toxins is best, there are times when we may need to support your body's natural detoxification pathways and processes. Determining the state of the liver and how well it is functioning is critical in proper detoxification. Evaluating their function through this preliminary questionnaire can guide our practitioners along your healing journey and help determine if further testing is necessary or to track the success of treatment in cases of liver dysfunction.

Gluten Questionnaire

The Gluten Questionnaire is for patients going through our wellness evaluation that are dealing with inflammatory concerns (asthma, allergies, general inflammation, etc), auto-immune or immune problems, intestinal or digestive issues, food sensitivities, and/or bowel issues. This short, easy questionnaire is the starting point for recognizing gluten sensitivities. For more complete testing, we offer cellular reactivity testing to foods, herbs and spices, and more. See our for more information.

Candida and Yeast Questionnaire

The Candida Questionnaire is for patients going through our wellness evaluations that are dealing with immune dysyfunction, intestinal or digestive issues, yeast imbalance and chronic infections. This short, easy questionnaire is the starting point for recognizing candida overgrowth. For more complete testing, we offer cultures and testing through outside labs if necessary. See our for more information.

Enzyme Deficiency Test for Endocrine Dysfunction

The Enzyme Deficiency Test is for patients who have any chronic endocrine dysfunction including but not limited to: upset stomach, constipation, diarrhea, gas, bloating, heart burn, acid reflux, IBD and other bowel disorders, gut and intestinal issues, blood sugar problems, chronic fatigue, and other digestive issues.

Ayruvedic DOSHA Test

According to Ayurveda, each of us has a unique mix of three mind/body principles, which creates our specific mental and physical characteristics. These three principles are called doshas. Most of us have one or two doshas, which are most dominant in our nature, with the remaining one(s) less expressed. Known as mind-body types, the doshas express particular patterns of energy—unique blends of physical, emotional, and mental characteristics. This test can help you determine which type you are in Ayurveda traditions.

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