Chiropractic Client Intake Form
Patient Information
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Last 4 Digits of Social Security #:
*
Email Address:
*
example@example.com
Address (Home):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Mobile):
Please enter a valid phone number.
Format: (000) 000-0000.
Phone (Home):
Please enter a valid phone number.
Format: (000) 000-0000.
Marital Status:
*
Please Select
Single
Married
Divorced
Separated
Widowed
Life Partner
Other
Tobacco Use:
*
Please Select
Never
Occasional/Social
Daily
Former
Pregnant or Trying? (Women Only)
Please Select
Yes
No
Unknown (Possible)
Employment Status:
*
Please Select
Full-Time Employed
Part-Time Employed
Self-Employed
Not Employed
Full-Time Student
Part-Time Student
Child
Retired
Disabled
Home-Maker
Military(Active Duty)
Other
Employer Name:
Employer Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Name:
*
First Name
Last Name
Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship:
*
Phone Type:
*
Home
Mobile
Work
Other
Insurance Information
Do You Have Insurance?
*
Yes
No
Policy Holder
Name:
*
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Phone (Mobile):
Please enter a valid phone number.
Format: (000) 000-0000.
Phone (Home):
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Name:
*
Policy ID#:
*
Policy Group ID #:
*
Social Security #:
Insurance Plan (i.e. HMO, PPO, etc.):
Relationship to Patient:
Do you Have Medical Coverage?:
Employer Name (Policy Holder):
Employer Phone (Policy Holder):
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party Information
Relationship to Patient:
*
Self
Spouse
Parent
Other
Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Social Security #:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone (Mobile):
Please enter a valid phone number.
Format: (000) 000-0000.
Phone (Home):
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Status:
Please Select
Full-Time Employed
Part-Time Employed
Self-Employed
Not Employed
Full-Time Student
Part-Time Student
Child
Retired
Disabled
Home-Maker
Military(Active Duty)
Other
Employer Name:
Employer Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Complaint Summary:
Describe Complaint:
*
How and When Did it Begin?
*
Describe the Pain Intensity:
Is Your Pain?
*
Minimal
Slight
Moderate
Severe
Sharp
Stabbing
Dull
Achy
Stiff/Sore
Other
Frequency of Complaint:
*
Intermittent
Occasional
Frequent
Constant
Does This Pain Radiate to Other Areas of Your Body (If so, where?):
*
Forehead
Base of Skull
Side(s) of Head
Temple
Shoulder(s)
Forearm(s)
Hand(s)/Finger(s)
Hip(s)
Calf(s)
Foot/Feet/Toe(s)
Thigh(s)/Knee(s)
Other
List Daily Activities Most Affected by this Complaint:
*
List Any Treatment You Have Received for This Complaint:
*
Have You Taken Any Medications?
*
Yes
No
If You Answered ‘Yes’ Above, Please List What You Have Taken (Prescriptions or OTC):
Have You Had Any Diagnostic Testing Performed for Above Complaint?
*
X-Ray(s)
CT Scan
MRI
No Tests Have Been Performed
Other
Health Summary
Please List Current Medications Including How Often and Dosage
Any Allergies to Any Medications (List Below):
Relevant Major Health Problems in Your Immediate Family:
List Any Major Surgeries Received and Date:
Check Below Any Symptoms You’ve Had (Current/Historical):
Headache
Migraine
Neck Pain
Joint Pain
Shoulder Pain
Chest Pain
Asthma
Difficulty Breathing
Skin Problems
Arthritis
Dizziness
Bruise Easily
Upper Back Pain
Lower Back Pain
Hearing Loss
Frequent Colds
Excessive Gas
Diarrhea
Constipation
Heart Attack
ADHD/ADD
Eating Disorder
Sciatica
Anxiety Disorder
Varicose Veins
Stroke
Depression
High Blood Pressure
Learning Disability
Trouble Sleeping
Ear Infection
Low Blood Pressure
Hearing Loss
Gall Bladder Issues
Cancer
Prostate Issues
Submit
Should be Empty: