Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Chiropractic Intake Form Template

Streamline Patient Assessments with This Useful Form

Getting comprehensive patient information can be a challenge, but our Chiropractic Intake Form Template simplifies the process for you. Designed for chiropractors, this template helps you gather essential health history and current concerns to tailor your treatment effectively. Enjoy benefits like improved patient communication, organized health records, enhanced treatment planning, and faster intake processes, all while ensuring compliance with WCAG-aligned standards. Start using the template today to enhance your practice.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If you prefer to self-describe your gender, please specify
Mailing address (street, city, state, ZIP)
Email address
Mobile phone number
Preferred contact method
Phone call
Text message
Email
No preference
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Prefer not to say
Other
Please Specify:
Do you have health insurance you plan to use?
Yes
No
Insurance company name (if applicable)
Member ID / Policy number (if applicable)
Policyholder name (if applicable)
Are you the primary insured?
Yes
No
Employer (if claim is work-related)
Responsible party for payment
Self
Parent/Guardian
Spouse/Partner
Other
Please Specify:
Is this visit due to a new concern?
Yes
No
Primary area of concern
Please Specify:
Side of symptoms
Left
Right
Both
Central
Not sure
Not applicable
When did the current symptoms start?
How did this start?
Motor vehicle accident
Work-related injury
Sports injury
Fall
Gradual onset
Posture/overuse
Not sure
Other
Please Specify:
Describe your symptoms
Pain intensity now
No pain
Mild
Moderate
Severe
Worst possible
Pain frequency
Never
Rarely
Sometimes
Often
Always
What aggravates your symptoms?
What relieves your symptoms?
Have you had any imaging for this problem?
X-ray
MRI
CT scan
Ultrasound
None
Not sure
Have you received chiropractic care before?
Yes
No
What are your goals for care?
Reduce pain
Improve mobility
Improve posture
Improve function for daily activities
Improve athletic performance
Stress reduction/relaxation
Maintenance/wellness
Other
Please Specify:
Current medications and supplements
Medication or other allergies
Past surgeries or hospitalizations
Conditions you have been diagnosed with (check all that apply)
Please Specify:
Family history (close relatives) of any of the following
Heart disease
Stroke
Diabetes
Cancer
Osteoporosis
Arthritis
None
Other
Please Specify:
Are you currently pregnant or possibly pregnant?
Yes
No
Implantable devices or metal in your body
Pacemaker/Defibrillator
Spinal cord stimulator
Joint replacement
Metal implants/screws/plates
None
Other
Please Specify:
Occupation
Main work activities
Desk/computer work
Manual labor
Driving
Standing most of the day
Repetitive lifting
Repetitive overhead work
Not currently working
Other
Please Specify:
Typical physical activity level
Low
Moderate
High
Prefer not to say
Tobacco use
Never
Former
Current some days
Current every day
Prefer not to say
Alcohol use
Never
Rarely
Sometimes
Often
Prefer not to say
Sleep quality in the past week
Very poor
Poor
Fair
Good
Very good
How much do symptoms interfere with daily activities?
Not at all
A little
Moderately
Quite a bit
Extremely
Preferred appointment times
Morning
Midday
Afternoon
Evening
No preference
Appointment reminders
Text message
Email
Phone call
No reminders
Permission to leave a voicemail or text with appointment information
Yes
No
Primary language
Do you need an interpreter?
Yes
No
I consent to chiropractic evaluation and treatment as deemed appropriate by the provider
Yes
No
I acknowledge receipt of the Notice of Privacy Practices (HIPAA)
Yes
No
I agree I am financially responsible for charges not covered by insurance
Yes
No
I authorize release of information to my insurer for claims processing
Yes
No
Patient signature (type full legal name)
Date signed
If patient is a minor: Parent/guardian full name
Relationship to patient
Parent
Legal guardian
Not applicable
Other
Please Specify:
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Gender","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a chiropractic intake form for FormCreatorAI article.

When to use this form

Use this form when you need a quick, complete snapshot before an adjustment or exam. Send it in your appointment confirmation, or hand it off on a tablet at check-in for new or returning patients. It captures symptoms, pain location, red flags, and consent so you can triage and plan care faster. Pair it with the New patient information form for contact and insurance basics, the Patient demographic information form for address and age, and the Medical history form to screen past injuries or conditions. This saves time for solo providers, front-desk teams, and multi-clinic groups, and it keeps records consistent across visits.

Must Ask Chiropractic Intake Questions

  1. What is your main concern today, and where do you feel it?

    This focuses your exam and maps pain to specific regions, so you can test what matters first. Basic details belong in the Patient information form, so this question stays clinical.

  2. When did the problem start, and what makes it better or worse?

    Onset, patterns, and triggers help you tell acute strain from chronic dysfunction. You can suggest short-term activity changes and choose safe techniques.

  3. Have you had injuries, surgeries, or medical diagnoses related to your spine, joints, or nerves?

    Prior issues flag risks and guide modifications during manual therapy. This protects patients with concerns like osteoporosis, disc herniation, or nerve symptoms.

  4. What medications or supplements are you taking, including blood thinners or pain relievers?

    Some drugs raise bleed risk or mask pain, which affects soft-tissue work and reassessment. Listing supplements helps you avoid interactions and set safe dosing advice.

  5. Have you seen a chiropractor or other manual therapist before? What treatments helped or did not help?

    Knowing what helped or failed shows likely responders and what to skip. It also sets expectations and builds trust through continuity.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel