New Chiropractic Intake Form
Connecting the Disconnected Since 2008
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Spouse's Name
Number of Children
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about Core Health?
Please Select
Friend or Family
Google
Facebook
Instagram
Pride of Dakota
Community Event
Other
Daily Pain Level Rating
Best
1
2
3
4
Worst
5
1 is Best, 5 is Worst
Primary Complaint:
*
Where is your primary complaint located?
*
Head/Neck
Shoulders
Arms
Back
Hips
Legs
Feet
Other
Medications:
Medications:
Medications:
Medication List Upload
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Please describe how the injury, pain or discomfort originated:
Please describe your pain or discomfort:
Choose a frequency you experience pain/symptoms from this condition:
Always
Hourly
Daily
Occasionally
Does this condition interfere with any of your daily activities or routines?
Yes
No
Has this condition affected your sleep?
Yes
No
Have you received any treatment for this injury/condition?
Yes
No
(Female Only) Are you pregnant, or have you had signs of pregnancy?
Yes
No
(Female Only) Are you planning to get pregnant in the next 12 months?
Yes
No
Health Concern
*
Broken Bones
Major Strain/Sprain
Eating Disorder
Been Hospitalized
Had Surgery
Auto Accident
Been Struck Unconscious
Had A Stroke or Heart Issue
Other
Any Checked Boxes Above? Explain here:
Family Health History:
Family Health History:
Health Problems
*
By signing below:
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge.
I consent to the collection and use of the above information to this office of chiropractic.
I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctors to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me.
I understand and agree that all services rendered to me will be charged to me, and I'm responsible for a timely payment of such services.
I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Signature
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