Chiropractic Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Phone
Email
Address
City
State/Province
ZIP/Postal Code
Emergency Contact
Name
Relationship
Phone
Insurance Information
Insurance Provider
Policy Number
Name of Insured
Health Information
What is your primary complaint?
When did this problem begin?
Have you had previous treatment for this condition?
Current Medications
Allergies
Medical History
Hospitalizations/Surgeries
Please check any conditions you have had (or currently have):
Arthritis
Cancer
Diabetes
Heart Disease
Stroke
Other
Other Conditions
Lifestyle
Do you smoke?
No
Yes
Do you consume alcohol?
No
Yes
Do you exercise?
No
Yes
Additional Information
Is there anything else you would like the doctor to know?