Chiropractic Intake Form: What to Include for New Patient Evaluations

Chiropractic intake forms need to go deeper than generic medical history. You're assessing the spine, the musculoskeletal system, and the daily habits that contribute to a patient's condition. A form that captures this well saves 15-20 minutes per new patient evaluation and gives you a clearer clinical picture before you even begin the exam.

Contact Information and Demographics

Name, date of birth, address, phone, email, emergency contact, employer. Include occupation and a brief description of daily work activities. A construction worker and an accountant with the same chief complaint often have very different contributing factors.

Chief Complaint and Pain Assessment

Start with why they're here:

• Primary complaint, in their own words
• When the problem started
• Gradual onset vs. specific incident
• Pain location, ideally a body map where they can indicate the area
• Pain scale (0-10) at rest, with movement, and at worst
• Pain quality: sharp, dull, aching, radiating, burning
• Frequency: constant, intermittent, only with certain activities
• What makes it better and worse

Radiating pain is particularly important in chiropractic. If a patient reports low back pain that shoots down their leg, that's a different clinical picture than localized lumbar pain. Build this as a conditional follow-up: "Does your pain radiate to other areas?" triggers fields for radiation pattern.

Spinal and Musculoskeletal History

This section is chiropractic-specific:

• Previous chiropractic care (where, when, what techniques, outcomes)
• Previous spinal surgeries or injections
• History of herniated or bulging discs
• Scoliosis diagnosis
• History of fractures, especially vertebral
• Neck or back injuries from accidents, falls, or sports
• Current or previous use of orthotics, braces, or supports

If the patient has had prior chiropractic care, knowing which techniques were used (Diversified, Activator, Gonstead, Thompson) and whether they were effective shapes your treatment approach immediately.

Accident and Injury History

Many chiropractic patients come in after an auto accident or workplace injury. Capture:

• Auto accident details (date, your role in vehicle, speed, direction of impact)
• Workers' compensation status
• Slip and fall incidents
• Sports injuries
• Claim number and attorney information, if applicable

Use conditional logic here. If the patient selects "auto accident" or "workplace injury," show the relevant detail fields. Otherwise, keep the form clean.

Lifestyle and Ergonomic Factors

These matter more in chiropractic than most specialties:

• Work environment: sitting vs. standing, desk setup, repetitive motions, heavy lifting
• Activity level: exercise type and frequency
• Sleep position: side, back, stomach, and mattress age
• Stress level: contributes to muscle tension and postural habits
• Daily screen time: relevant for cervical complaints

Imaging History

Has the patient had prior X-rays, MRI, or CT scans of the relevant area? If so, when, where, and what were the findings? Include a file upload field for patients who have digital copies.

Medical History and Medications

Current medications, supplements, allergies, and relevant medical conditions. Pay special attention to osteoporosis, inflammatory arthritis, cancer history, and blood clotting disorders, as these are contraindications or precautions for certain adjustment techniques.

Treatment Goals

What does the patient want to achieve? Pain relief, improved mobility, better posture, return to a specific activity? Documented goals create shared expectations and measurable outcomes.

Consent

Informed consent for chiropractic treatment, including a clear explanation of adjustment risks. E-signature fields make this legally clean and easy for the patient.

Putting It Together

Formisoft's AI form builder can generate a chiropractic-specific intake form in seconds, covering all of these sections. Customize with conditional logic so accident and workers' comp fields only appear when needed, and use multi-page layout to keep the form from feeling overwhelming.

Send it to patients before their first visit. They complete it on their phone, you review it before the exam, and the first appointment focuses on the patient, not the paperwork.

Try Formisoft free and build your chiropractic intake form.