Chiropractic Reassessment Intake Form
Please complete this form before your chiropractic reassessment visit so we can review your current symptoms, progress, and care needs.
Patient and Visit Details
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Email
*
example@example.com
Reassessment Visit Date and Time
*
Reassessment Clinical Information
Reason for Today's Reassessment
*
Please Select
Routine follow-up
New concern
Worsening symptoms
Improvement check
Treatment progress review
Other
Current Primary Complaint
*
Symptom Change Since Last Visit
*
Improved
No change
Worsened
Fluctuating
Unsure
Pain Location(s)
*
Neck
Upper back
Mid back
Lower back
Left shoulder/arm
Right shoulder/arm
Left leg
Right leg
Other
Pain Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Frequency, Duration, and Aggravating or Relieving Factors
*
Functional Status and Treatment Response
Change in daily activities or function since the last visit
*
Improved
No change
Worsened
Response to previous chiropractic care
*
Helpful
Somewhat helpful
No change
Made symptoms worse
Current home exercises or self-care being followed
Stretching
Strengthening
Heat/ice
Rest/activity modification
Ergonomic changes
Other
Medications or other treatments currently used for this issue
New symptoms or health changes relevant to chiropractic care
Submit Reassessment
Should be Empty: