Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Chiropractic Intake Form
Chiropractic Patient Intake Form Please fill out this form completely so we can better understand your condition and develop an effective treatment plan.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Occupation
Address *
Pain Assessment & Medical History Describe your symptoms and medical background to help us determine the best course of care.
Primary Complaint *
When Did Symptoms Start? *
Current Pain Level (1-10) *
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Pain Location *
- Neck
- Upper Back
- Mid Back
- Lower Back
- Left Shoulder
- Right Shoulder
- Left Hip
- Right Hip
- Left Leg
- Right Leg
- Headaches
Pain Type
- Sharp
- Dull
- Aching
- Burning
- Throbbing
- Tingling
- Numbness
What Makes It Worse?
What Makes It Better?
Have You Received Chiropractic Care Before? *
- Yes
- No
Previous Treatments Tried
- Physical Therapy
- Massage
- Medication
- Surgery
- Injections
- None
Daily Activity Level *
- Sedentary
- Light
- Moderate
- Active
Allergies
Current Medications
Medical Conditions
Chiropractic Intake Form template from formisoft.com. formisoft.com/intake-templates/chiropractic-intake