General / Adult Intake

General / Adult Intake

Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Sex
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Address*
City
State/ ZIP
Occupation
Employer
Marital Status
Spouse / Partner Name
Children's Names & Ages
Who referred you?
Hobbies / Interests

Previous Care
Prior Chiropractor
Last Appointment with Prior Chiropractor

MonthDayYear
Prior Chiropractor Address
Prior Chiropractor Phone
Please enter a valid phone number.Format: (000) 000-0000.
General Practitioner
GP Phone
Please enter a valid phone number.Format: (000) 000-0000.
YesNo

Reason for Visit
Health Reason 1*
Health Reason 2
Health Reason 3
Health Reason 4
In the past week, how much has pain interfered with daily activities? (0-10 being the most)

Imaging & Injury History
YesNo
If yes — date & area / type
YesNo
YesNo
If injury — when?
YesNo
Other doctors who treated this problem
Any family members with similar problems?

Health History
Check all that apply
Tobacco use — type & frequency
Cancer / tumor (explain)
Surgeries
Medications
Other health problems

Chiropractic Knowledge
What have you heard about chiropractic?
YesNo
Insurance & Payment
YesNo
Insurance Plan
CashCheckCredit Card
Signature
The above information is true and accurate to the best of my knowledge. My reason for consultation is for evaluation of my physical health and the potential for improvement.
Patient or Guardian Signature*
Type your full name as your signature
Date*

MonthDayYear
Date
Should be Empty: