Chiropractic Intake Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Emergency Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Referred by?
Medical Data
Purpose of visit or complaint
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
Have you been treated by a Medical physician for this condition?
Yes
No
If so, when?
-
Month
-
Day
Year
Date
Have you been treated by another Chiropractor for this condition?
Yes
No
If "yes" when?
-
Month
-
Day
Year
Date
If "yes" by whom?
Have you experienced these symptoms before?
Yes
No
If "yes" when did your symptoms start?
-
Month
-
Day
Year
Date
What makes your symptoms feel better (ice, heat, rest, stretch, etc?)
What makes your symptoms worse (ice, heat, rest, stretch, etc?)
Are your symptoms local, or do they travel to another area? (if they travel, to where?)
Are your symptoms constant, occasional, frequent, other?
Is pain worse in the morning, or evening?
Morning
Evening
No specific times
Other
Health Condition
Hypertension
Heart issues
Rashes
Diabetes Mellitus
Bone problems
Blood Clooting
Spams/Cramps
Sprains
Varicose Veins
Constipation
Arthritis
Seizure
Spinal Cord Issues
Chronic cough
Asthma
Neck pain
Back pain
Hips pain
Legs pain
Infectious diseases
Vision problem
Kidney disorder
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Are you smoking? If yes, how many packs a day?
Do you exercise daily?
Yes
No
What type of exercises you do?
Strenuous
Moderate
Light
None
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
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:
Have you experience any pain in any part of your body? If yes, please indicate what body part. Please be specific.
In scale of 1-10, how much pain are you feeling right now?
1
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
What type of pain are you experiencing?
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
Spasms
Shooting pain
Achy
Throbbing
Have you have family history of the following medical diagnosis?
Cardiovascular disease
Diabeter Mellitus
Cancer
Asthma
Arthritis
Authorization and Consent
I confirm that all information given in this form is true, complete, and accurate.
Signature of the Patient
Clear
Submit
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