Chiropractic Intake Form

Chiropractic Care Pre-Visit Intake

Chief Complaint & Pain Details

Please describe your primary pain, discomfort, or health concern in detail: * Required

When did this current episode or condition first begin? * Required

How did this issue or pain start? * Required

How would you describe the character of the pain? (Select all that apply) * Required

SharpDull & AchingBurningThrobbingShootingNumbness & TinglingConstant (does not go away)Intermittent (comes and goes)

Does the pain radiate or travel to other areas of your body? (Select all that apply) Optional

No, stays in one placeDown the left armDown the right armDown the left leg (sciatica)Down the right leg (sciatica)Into the hips or buttocksFrom the neck up into the head (headaches)

Pain Severity & Modifying Factors

Rate the severity of your pain at its WORST (1 = Mild/Barely Noticeable, 10 = Unbearable/Severe): * Required

12345678910

Rate the severity of your pain at its BEST (1 = Mild/Barely Noticeable, 10 = Unbearable/Severe): * Required

12345678910

What activities or positions make the pain WORSE? (Select all that apply) Optional

SittingStandingWalkingBending forwardBending backwardLifting objectsLying downCoughing, sneezing, or straining

What makes the pain feel BETTER? (Select all that apply) Optional

RestMovement or walkingHeat packIce packStretchingMassage therapyPrior chiropractic adjustmentsPain medication / Anti-inflammatories

Prior Care & Red Flags

Which providers have you already consulted for this specific complaint? (Select all that apply) Optional

None (this is my first consultation)Primary Care Physician (PCP)Another ChiropractorPhysical Therapist (PT)Orthopedic SurgeonMassage TherapistAcupuncturist

Are you currently experiencing any of the following symptoms? (Select all that apply) * Required

Unexplained weight lossFever, chills, or night sweatsRecent changes in bowel or bladder functionNumbness in the groin/saddle areaProgressive weakness or loss of coordination in arms/legsSevere pain at night that wakes you from sleepNone of the above

Chiropractic Intake Form

Preview