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Chiropractic new patient intake form template

New patient intake for chiropractic clinics: complaint, pain scale, history and consent.

19 questions · 3 pages · fully editable

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Page 1 · About you

Full name *

Email *

Phone *

Date of birth *

Street address

City

State / Province

ZIP / Postal code

How did you hear about us?

Page 2 · Your visit

Main reason for your visit *

Where is the problem? * Neck
Upper back
Lower back
Shoulder
Hip
Knee
Headaches
Other

When did it start?

How did it start?

Pain level right now (0 = none, 10 = worst) *

What makes it worse? Sitting
Standing
Walking
Lifting
Bending
Sleeping

Page 3 · Health history

Have you had any of these? * Surgery
Fractures
Osteoporosis
Arthritis
Cancer
Pregnancy (current)
None of these

Current medications

Family doctor

I consent to examination and chiropractic care. My chiropractor will explain the treatment plan and any risks before treatment begins.

Signature *

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Align ChiropracticChiropractor websiteA clinic site with the new-patient intake built in.Preview the site →

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