Chiropractic intake form
A chiropractic intake form collects the chief complaint, pain level, and medical history a chiropractor needs before the first adjustment. This helps the practitioner assess range of motion, plan the care course, and identify contraindications.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
A pain-level rating gives the chiropractor immediate urgency context
A 9/10 signals acute pain that may need gentle technique; a 2/10 suggests the patient is there for maintenance.
Previous chiropractic care history reveals whether the patient knows what to expect
New patients need more education about the process; returning patients can move straight to assessment.
No card required.
Chiropractic Intake Form
Live previewHow to build this form
6 steps in the editor. Nothing here needs a paid plan.
- Add text and email fields for patient name and email.
- Add a date field for date of birth.
- Add a phone field for patient contact.
- Add a dropdown or textarea for reason for visit — e.g. "back pain", "neck pain", "injury", "wellness".
- Add a rating or slider for current pain level (0–10).
- Add a radio or checkbox for previous chiropractic care (yes/no).
Fields in this form
8 fields, using 8 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Full name | Short text | Yes |
| Email address | Yes | |
| Phone number | Phone | Yes |
| Date of birth | Date | Yes |
| Reason for visit | Dropdown | Yes |
| Current pain level (0 = none, 10 = severe) | Slider | Yes |
| Have you seen a chiropractor before? | Radio buttons | Yes |
| Relevant medical or injury history (optional) | Long text | Optional |
What goes wrong with this form
Specific to a chiropractic intake form, not general advice about forms.
Using an open text field for reason-for-visit instead of a dropdown
Dropdowns like "back pain", "neck pain", "injury" make it easy for patients to select and keep responses consistent.
Skipping the pain-level rating
The chiropractor needs to know severity upfront to adjust technique intensity and session duration.
Not asking about previous chiropractic care
First-time patients may be nervous about manipulation. Knowing they're new lets you explain the process first.
Questions about this form
Is this form HIPAA-compliant?
This is a general intake form, not a clinical record system. If you operate under HIPAA, you are responsible for compliance.
Should I ask about current medications?
Yes, if relevant to your practice. Add an optional textarea for medications or supplements so the chiropractor can note drug interactions or contraindications.
Can I ask whether a patient has had X-rays or MRI?
Absolutely. Add a checkbox section for imaging the patient has had (X-ray, MRI, CT) so you know whether new imaging is needed.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Medical HistoryCollect a new patient's medical background before the first appointment.
- Insurance VerificationCollect insurance details before the appointment so staff can verify coverage manually.