Chiropractic Client Intake Form

HISTORY QUESTIONNAIRE

First Name:

Last Name:

Date of Birth:

Patient ID#

Please answer the following questions accurately. If you are unsure about a certain question, please ask.

In your own words, what is your chief complaint?

What caused the pain to start?

When did it start?

Did you receive any treatment?

Yes No

What treatment?

Did it help?

Where do you feel the pain?

Did the pain/symptoms spread?

Do you experience numbness, tingling, and/or weakness? If so, which and where?

If you were involved in an accident, describe WHEN and HOW it happened:

Have you previously seen a chiropractor?

Yes No

When was your last visit? Were you treated for the same complaint?

Medications, doses, or supplements:

Please list all surgeries (type of surgery and date)

Employer Name:

Employer Phone Number:

Currently working?

Yes No

Missed work:

Last day of work:

Are you collecting disability?

Yes No

If yes, what type of disability?

Do you smoke?

Yes No

If yes, how much do you smoke per day?

How often do you drink alcohol?

Have you ever smoked in the past?

Yes No

When did you stop?

Do you take any nutritional supplements?

Yes No

If so, what and how much?

Do you have any children?

Yes No

If yes, how old are they?

Medical/Imaging Reports

Add file

Please upload a file

Patient and Insurance Information

First Name

Middle Initial

Last Name

Date

Address

Apt #

City

State

Zip

Home Phone

Work Phone

Cell Phone

Preferred Method of Contact

Email Address

Preferred Method of Contact

D.O.B.

Soc Sec #

Marital Status

M S D Sep

Spouse Name

# of Children

Referred By:

Occupation

Emergency Contact

First Name:

Last Name:

Phone:

Relationship:

Address

Family Physician Name and Number:

Health Insurance Information

Do you have Health Insurance?

Yes No

Carrier

Ins Co. Phone

Ins Co. Address

Insurance Policy #

Insurance Group #

Patient Relationship to the Insured

Self Spouse Child Other

Name of Insured

Address of Insured

Phone of Insured

Sex

D.O.B.

SS #

Insured's Employer

Address

Phone

Plan Name

Copy of Insurance card

Add file

Please upload a file

Auto Accident Insurance

Was this condition the result of an Auto Accident?

Yes No

Carrier

Policy Number

Address

City

State

Zip

Phone

Person to Contact

Claim #

Date of Accident

Patient Relationship to the Insured:

Self Spouse Child Other

Click here to view: HIPAA Policy

Click here to view: Financial Responsibilities & Assignment of Benefits

Click here to view: Missed Appointment Policy

Please check that you have read and understand the following agreements

HIPAA Policy

Financial Responsiblities

Missed Appointment Policy

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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Chiropractic Client Intake Form

HISTORY QUESTIONNAIRE

Patient and Insurance Information

Emergency Contact

Health Insurance Information

Auto Accident Insurance

Click here to view: HIPAA Policy

Click here to view: Financial Responsibilities & Assignment of Benefits

Click here to view: Missed Appointment Policy

Be Well Chiropractic Health & Wellness Center