Chiropractic Intake Form

First Name

Last Name

Date of birth

Occupation

Gender

Contact Information

Phone number

Email address

Address

Emergency Contact

Add Emergency Contact Number

Primary Care Physician

First Name

Last Name

Phone number

Address

Medical History

Is this your first visit to a chiropractor?

Yes No

What medications are you taking (if any) and for what conditions?

Do you have any medication allergies?

Do you have any pre-existing medical conditions?

Example: Asthma, heart conditions, etc

Have you had any past fractures, sprains, or breaks? If so, include the type of injury, location on your body, and when the injury occurred.

List any recent or upcoming surgeries.

Are you pregnant?

Yes No Not Sure

If yes, how far along?

Is there anything else regarding your medical history that we should be aware of?

Lifestyle

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you exercise?

Regularly Occasionally No

Do you have a healthy and balanced diet?

Regularly Occasionally No

How are your stress levels?

Regularly Occasionally No

Reasons for Visit

Are you here as a result of a motor vehicle accident?

Yes No

Are you here as a result of a workplace injury?

Yes No

Describe the reason you are seeking chiropractic treatment.

When did the symptoms start?

Describe anything you think might have caused the symptoms.

Examples: Working out, posture, sleeping, etc.

Describe anything you think might aggravate the symptoms.

Examples: Reaching for items, sitting for an extended amount of time, etc.

Describe any other treatments you’re receiving for your symptoms.

Examples: Acupuncture, physical therapy, etc.

Have you experienced these types of symptoms before?

Yes No

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