Intake Forms

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone

Birth Date*

Sex

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Number of Children

Employer

Occupation

Spouse's Name

First Last

Spouse's Date of Birth

Emergency Contact*

First Last

Emergency Phone*

Height

Weight

Email*

Whom may we thank for referring you?

Have you consulted a chiropractor before?*

No
Yes

When?

Please check any condition that you've had or currently have:

What are your allergies?

What type of cancer do you have?

Is your mother still living?

Yes
No

Please indicate if there is history on your mother's side for any of the following:

Diabetes
Heart
Kidney
Cancer
Back

Is your father still living?

Yes
No

Please indicate if there is history on your father's side for any of the following:

Diabetes
Heart
Kidney
Cancer
Back

List operations, broken bones, or dislocations you have had in the past 5 years (type and date)

List actual name and dosage of any prescription medications you are currently taking*

Smoking Status*

Smoker
Previous smoker
Never smoked

The symptom(s) that have prompted me to seek care today include:*

Are they the result of...?*

Work Accident
Auto Accident
Other accident
Non-accident related
An acute problem that recently came on
A worsening long-term problem

When did you first notice your current symptoms?

On a pain scale of 1-10 with 0 being no pain and 10 being the highest possible level of pain, where do you grade your pain today?*

Intensity is:

The complaint came on:

Gradually
Immediately

It is getting:

Better
Staying the same
Getting worse

Frequency of this complaint is:

Intermittent
Occasional
Frequent
Constant

Does it affect other areas of your body? To what areas does the pain radiate, shoot, or travel?

What does the pain feel like?

Please describe where on your body the pain occurs

What tends to worsen the problem? (Time of day, movements, certain activities, etc)

What tends to lessen the problem? (Time of day, movements, certain activities, etc.)

What have you done to relieve the symptoms?

Prescription medication
Surgery
Ice
Over-the-counter drugs
Heat
Physical Therapy
Chiropractic
Massage

What can't you do now because of this problem that you would like to be able to do again?

Intake

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