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Chiropractic Intake Form

Collect a new patient's medical history and contact details ahead of their first chiropractic visit so the practitioner can plan the right course of treatment.

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Full Name

First Name

Last Name

Age

Date of Birth

Gender

Phone Number

Occupation

Address

Street Address

City

State / Province

ZIP / Postal Code

Emergency Contact Person

First Name

Last Name

Phone Number

Relationship

Medical Doctor's Name

First Name

Last Name

Phone Number

Hospital Name

Purpose of visit or complaint

When did you start experiencing this problem?

Health Condition

Diabetes Hypertension Asthma Heart Disease Arthritis None

Are you pregnant, breastfeeding, or nursing? (Female)

Yes No Not applicable

Are you smoking? If yes, how many packs a day?

Do you exercise daily?

Yes No

What type of exercises do you do?

Cardio Strength training Yoga/Stretching Sports Other

Are you wearing any implantable medical devices? If yes, what are these devices?

Were you previously hospitalized? If yes, please indicate when and why:

Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:

Do you feel pain in any part of your body? If so, please indicate which part specifically.

On a scale of 1-10, how much pain are you feeling right now?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

What type of pain are you experiencing?

Sharp Dull Throbbing Burning Numbness Stiffness

Do you have a family history of any of the following medical diagnoses?

Diabetes Heart Disease Cancer Arthritis High Blood Pressure None

I certify that the information provided is accurate and complete.

Signature of the Patient

Sign here

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