Chiropractic Intake Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Person
Medical Doctor's Name
Purpose of visit or complaint
When did you start experiencing this problem?
Spinal Cord Issues
Are you pregnant, breastfeed, or nursing? (Female)
Are you smoking? If yes, how many packs a day?
Do you exercise daily?
What type of exercises you do?
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Have you experience any pain in any part of your body? If yes, please indicate what body part. Please be specific.
In scale of 1-10, how much pain are you feeling right now?
1 is Worst, 10 is Best
What type of pain are you experiencing?
Have you have family history of the following medical diagnosis?
Authorization and Consent
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information
Signature of the Patient
Should be Empty: