Forms for First Visit

Please download and print your intake forms prior to your initial appointment.  If you are unable to have your intake forms before your visit, please arrive at least 15 minutes early to complete the forms in our office.  If you have problems with the files loading, please right click and save to your desktop for printing.


(Please download and complete the following four form links)

LEC New Patient Medical History

Review of Systems

QVAS and Pain Drawing

LEC Financial Policy



These forms below only need to be printed and completed if they pertain to your primary complaint. AND THEN, if these problems relate to you complete the corresponding form.

If you have HEADACHES

Headache Disability Index

If you have NECK PAIN

Neck Pain Disability Index

If you have LOW BACK PAIN

Revised Oswestry Disability Index


Other Forms and Information

Modified Elimination Diet

1023 E Capitol Ave, Bismarck, ND 58501

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