Chiropractic Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Address
City
State
ZIP
Phone
Email
Emergency Contact
Name
Phone
Relationship
Insurance Information
Insurance Provider
Policy Number
Group Number
Health Information
Primary Complaint/Reason for Visit
Describe your symptoms
Pain Level (1-10)
Have you received chiropractic care before?
Yes
No
Medical History
List any medical conditions
List any current medications
List any allergies
Lifestyle
Do you exercise regularly?
Yes
No
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Signature
Signature
Date