Patient Intake Form

Patient Intake Form
Patient Info
Name:

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email:
example@example.com
(if cell, may we text you? Yes/No)

YesNo
Age
DOB:

MonthDayYear
Date
Martial Status
Number of Children
Occupation
Name of Spouse
Emergency Contact Name
Are you pregnant? Yes No If yes, how far into pregnancy?
Emergency Contact Phone Number
Please enter a valid phone number.
Medical History
How did you hear about us?
Have you been to a chiropractor before? YES NO If yes, who?
List present complaints, injuries, and its duration:
Any prior xrays/MRIs of the area of complaint? YES NO If yes, when were they taken?
How did your problem begin?
Have you seen any other doctors regarding your present complaint? YES NO If yes, please list the doctors.
Name: Type of Doctor: When Consulted: Date
The pain is getting: Worse Better Staying the Same
What makes the pain better? What makes it worse?
How often is the pain present? Intermittent (<25%) Occasional (25-50%) Frequent (50-80%) Constant (80-100%)
Is your pain affecting your ability to do work or daily routine activities? Yes No Explain:
List prior surgeries: blanks
List former serious accidents and falls (auto, work, home, leisure, sports, etc.): blanks
List broken bones:blanks Current meds:
Other significant medical history:blanks
Work environment (choose one): sittingstanding walking heavy lifting bending
PAIN DIAGRAM
On the diagram below, please describe where you are experiencing your pain and the type.
Describe Pain and Location
PAIN SCALE
Rate the severity of your pain by selecting below from the following scale.

Rate your Pain
Should be Empty: