Patient Intake Form

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Patient Intake

Date
Name*

Sex
Email*

H. Phone*
W. Phone

Address

City
State
Zip

Date of Birth
Age
Referred by

Social Security #
Occupation

Status
How did you find us?

Have you ever received Chiropractic Care?
If yes, when?

Other factors contributing to the primary and secondary reasons:

1. Chief Complaint:

Location of Complaint:

Complaint Began when and how?

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where?

Do you have any numbness or tingling in your body? Where?

Grade Intensity/Severity (No complaint/pain)

(Worst possible pain/complaint imaginable)

How frequent is complaint present, how long does it last?

Does anything aggravate the complaint?

Does anything make the complaint better?

3. Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint:

A. Previous illnesses you’ve had in your life:

B. Previous injury or trauma:

Have you ever broken any bones? Which?

C. Allergies

D. Medications:
Medication
Reason for taking

E. Surgeries:
Date
Type of Surgery

F. Females/ Pregnancies and outcomes:
Pregnancies/Date of Delivery
Outcome

What was the date of the beginning of your last menstrual period?

4. Family Health History:
Associated health problems of relatives:

Deaths in immediate family:
Cause of parents or siblings death
Age at death

5. Social and Occupational History:
Associated health problems of relatives:

A. Level of Education:

B. Job description:

C. Work schedule:

D. Recreational activities:

Lifestyle (hobbies, level of exercise, alcohol, tobacco and drug use, diet):

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes.

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