Chiropractic Initial Intake Form

1
Name
First Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Date of Injury
Date
Year
Month
Day
4
Date of Service
Date
Year
Month
Day
5
Chief Complaint
Huge
Large
Normal
Small
Ok
Ok
6
Phone Number
Please enter a valid phone number.
7
Email* This field is required.
example@example.com
8
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Please pick any of the following that apply to you.* This field is required.
Joint Replacement
Diabetes
Arthritis
High/Low Blood Pressure
Cancer
Fibromyalgia
Anxiety
Epilepsy or Seizures
Osteoporosis
Heart Problems
Circulatory Problems
Numbness
Injury
None
10
Please describe your current injury and the event that caused it.Ex: I have discomfort when I bend my knee after falling playing soccer.
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Large
Normal
Small
Ok
Ok
11
List any past injuries that have caused a lasting impact. Ex: I tore my rotator cuff 4 years ago and and still feel discomfort when I play golf.
Huge
Large
Normal
Small
Ok
Ok
12
List any medications you are currently taking.* This field is required.Ex: Losartan 50mg Type none if not currently under any medication.
Huge
Large
Normal
Small
Ok
Ok
13
List any past surgeries you have had and the date of the procedureEx: Right Knee (ACL) Surgery, 06/18/2023
Huge
Large
Normal
Small
Ok
Ok
14
Do you suffer from frequent headaches?
YESNO
15
Headache Characteristics
Headache Location
Headache Location
Behind Head
Top of Head
Front of Head
Behind Eyes
Sides of Head
All Over
Please SelectHeadache Description
Throbbing
Tension
Pressure
Sharp
Dull
Headache
Headache Duration
Headache Duration
Intermittent
Constant
16
How does your neck feel?
Stiff
Achy
Tight
Sore
Good
17
How does your Upper Back feel?
Stiff
Achy
Tight
Sore
Good
18
How does your Lower Back feel?
Stiff
Achy
Tight
Sore
Good
19
How would you rate your discomfort?
Please Select
Please Select
Mild
Moderate
Intense
20
Do you have difficulty doing any of the following?
Lifting
Prolonged Sitting
Standing
Bending
Sleeping
Walking
Keeping Straight Posture
N/A
21
How many hours do you sleep on average?
Less than 3 hours
3-5 hours
5-7 hours
7+ hours
22
How long before you feel discomfort standing?
Less than 30 minutes
Less than 1 hour
Less than 2 hours
More than 2 hours
23
How long before you feel discomfort sitting?
Less than 30 minutes
Less than 1 hour
Less than 2 hours
More than 2 hours
24
How long before you feel discomfort walking?
Less than 30 minutes
Less than 1 hour
Less than 2 hours
More than 2 hours
25
Has your current physical condition caused a loss of enjoyment to any hobbies/sports that you're passionate about?If yes, list them and how they've been affected. Ex: My lower back pain has prevented me from going to the gym and doing yoga. My right knee pain has prevented me from playing Padel/Golf.
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Large
Normal
Small
Ok
Ok
26
Circle any areas you feel discomfort.
Should be Empty: