Online Forms

Chesapeake Chiropractic offers our patient form(s) online so they can be completed prior to your appointment, at your convenience.


NEW and RETURNING PATIENTS - Please complete the Initial Evaluation form (select pediatric, if appropriate) and the Compliant form.

Initial Evaluation form (non-accident, adults age 7 and older)

Pediatric Initial Evaluation form (ages 0 to 6 years)

Complaint form (PDF)

Complaint form (fillable)


AREAS OF COMPLAINT (Required - Please complete all applicable forms)

Neck Disability Index Questionnaire

Upper Extremity Pain Questionnaire

TMJ Disability Index (Jaw Pain)

Oswestry Questionnaire (Low Back Issues)

Lower Extremity Functional Scale


ACCIDENT RELATED INJURIES (If applicable)

Automobile Accident

Work Related Automobile Accident

Work Related Accident

Slip and Fall Accident

Sports Injury

Other Related Trauma


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Location

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Office Hours

Our Regular Schedule

Monday:

8:30 am - 12:45 pm

1:30 pm - 7:00 pm

Tuesday:

8:30 am - 12:45 pm

1:30 pm - 7:00 pm

Wednesday:

8:30 am - 12:45 pm

1:30 pm - 7:00 pm

Thursday:

8:30 am - 12:45 pm

1:30 pm - 7:00 pm

Friday:

8:30 am - 12:45 pm

1:30 pm - 7:00 pm

Saturday:

8:30 am-12:00 pm

Sunday:

Closed

Testimonials

Reviews By Our Satisfied Patients

  • "I have gone to chiropractors for about 15 years. I have had at least 5 steady chiropractors in those 15 years. I am proud to say that Karen and Lisa have been one of the best. Not only do they do good work, they are very caring and understanding. They sincerely care about their patients."
    Debbie B.
  • "My mother introduced me to this chiropractry because of my lower back pain. I have had this since I was 5, (I am 12 now) and not even surgeon's could tell why. I have also had childhood migranes and chronic ear infections. Since being treated and being given stretches, my migranes have decreased intensly. My posture has been helped immensely."
    Brendon D.
  • "Since receiving treatment over the past four months I have been able to move my neck left and right. I don't get dizzy when I tilt my head back. I've forgotten what pain I was in before I came here and a side effect is no more chronic earaches!"
    Dolores F.