McKinley Family Chiropractic Intake Form

Chiropractic Patient Intake Form

Please complete this form to help us provide you with the best possible care at your visit.
Patient Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Sex*

MaleFemale
Occupation*
Marital Status*

SingleMarriedWidowedOther
Number of Children*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
How did you hear about us? *
Primary Care Physician (if applicable)
Date of Last Doctor's Visit

MonthDayYear
Date
What is the main reason for your visit today?*
Where is your pain or discomfort located?*
Is the reason for your visit due to an injury? (motor vehicle, fall, sports injury)*

YesNo
If yes, please explain
How did your condition start?*

SuddenlyGradually
Is the condition:*

ImprovingGetting WorseStaying the sameUnsure
What makes the problem better?*
What makes the problem worse?*
How long have you had this issue?*
Have you received care for this condition before? *
If yes, what type of care did you receive?
Have you received chiropractic care before?*

YesNo
If yes, why did you decide to change offices?
What are your top three health goals? *
Please select any of the following conditions you have or have had:*

DiabetesHigh blood pressureHeart diseaseArthritisAsthmaCancerStrokeNone of the aboveOther
If other, please list conditions:
List any surgeries, hospitalizations, more accidents or major illnesses (with dates, if possible):
List any medications you are currently taking:
Do you have any allergies?*

YesNo
If yes, please list your allergies:
Is there any other information you would like us to know about your health?
Notable childhood injuries?*

YesNo
If yes, explain:
Youth or college sports injuries?*

YesNo
If yes, explain:
How often do you exercise?*

None1-3x per week4-6x per weekDaily
What kind of exercise?
How do you normally sleep?*

BackSideStomachUnsure
Do you wake up:*

Refreshed and readyStiff and tiredUnsure
Do you commute to work?*

YesNo
If yes, how long is your commute?
Alcohol *

1

2

3

4

5

1 is None, 5 is High
Water*

1

2

3

4

5

1 is None, 5 is High
Sugar *

1

2

3

4

5

1 is None, 5 is High
Dairy*

1

2

3

4

5

1 is None, 5 is High
Gluten*

1

2

3

4

5

1 is None , 5 is High
Processed Foods*

1

2

3

4

5

1 is None, 5 is High
Artificial Sweeteners*

1

2

3

4

5

1 is None , 5 is HIgh
Sugary Drinks*

1

2

3

4

5

1 is None, 5 is High
Cigarettes*

1

2

3

4

5

1 is None, 5 is High
Recreational Drugs*

1

2

3

4

5

1 is None, 5 is High
Stress around work*

1

2

3

4

5

1 is None, 5 is High
Stress around home life*

1

2

3

4

5

1 is None, 5 is High
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Chiropractic Patient Intake Form