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

Nombre

Apellido

Age

Date of Birth

Gender

Phone Number

Occupation

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency Contact Person

Nombre

Apellido

Phone Number

Relationship

Medical Doctor's Name

Nombre

Apellido

Phone Number

Hospital Name

Purpose of visit or complaint

When did you start experiencing this problem?

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?

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.

What type of pain are you experiencing?

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

I certify that the information provided is accurate and complete.

Signature of the Patient

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Chiropractic Intake Form

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