CHIROPRACTIC INTAKE FORM

1. Name: *
1. Name:
2. Is this related to a recent motor vehicle accident?
If you answer yes, please inform reception immediately
3. Is this related to a work related injury/accident?
If you answer yes, please inform reception immediately
Prior Care
4. Have you ever had X-Rays/CT/MRI?
If you answer yes, please tell us the date and area of the body
Primary Concerns
6. Date problem began:
6. Date problem began:
(aching, stabbing, numbness, etc.)
0 = no pain / 10 = worst pain imaginable
11. Is this concern:
How would you describe this pain in each of these areas: numbness, pins & needles, burning, aching, stabbing?
Past History
18. Have you ever suffered from:
Check all that apply
(i.e. arthritis, diabetes, cancer, heart disease)
(including dates and injuries)
26. Knocked unconscious or concussions:
29. Have you ever had chiropractic care before:
If you answer yes, please tell approximately when
31. Partner's name
31. Partner's name
33. Are you pregnant?
If you answer yes, let us know your due date and please inform the Doctor
Due date:
Due date: