Chiropractic Intake Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Emergency Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Medical Doctor's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Hospital Name
Medical Data
Purpose of visit or complaint
When did you start experiencing this problem?
-
Month
-
Day
Year
Date
Health Condition
Hypertension
Heart issues
Rashes
Diabetes Mellitus
Bone problems
Blood Clooting
Spams/Cramps
Sprains
Varicose Veins
Constipation
Arthritis
Seizure
Spinal Cord Issues
Chronic cough
Asthma
Neck pain
Back pain
Hips pain
Legs pain
Infectious diseases
Vision problem
Kidney disorder
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Are you smoking? If yes, how many packs a day?
Do you exercise daily?
Yes
No
What type of exercises you do?
Strenuous
Moderate
Light
None
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
2
3
4
5
6
7
8
9
10
Worst
Best
1 is Worst, 10 is Best
What type of pain are you experiencing?
Numbness
Sharp pain
Tingling
Burning
Dull pain
Stiffness
Have you have family history of the following medical diagnosis?
Cardiovascular disease
Diabeter Mellitus
Cancer
Asthma
Arthritis
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.
HIPAA:
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
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