Chiropractic Intake Form

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Occupation

Gender

Contact Information

Phone number

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Email address

Mailing Adress, City, State, Zip

Emergency Contact

Add another emergency contact

Primary Care Physician

First name

Last name

Phone number

Organization / Facility

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

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

Reason for Chiropractic Care (Chief Complaint)

When did the symptoms start?

How did this begin?

Examples: Working out, posture, sleeping, etc.

What makes your complaint worse?

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

What makes your complaint better / treatment you've had?

Examples: Acupuncture, physical therapy, etc.

Have you experienced these types of symptoms before?

Yes No

Mark the areas on the image where you are experiencing symptoms.

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Chiropractic Intake Form

Emergency Assistance

Client Information

Contact Information

Emergency Contact

Primary Care Physician

Medical History

Lifestyle

Reasons for Visit

Emergency Assistance

Clement Chiropractic