Chiropractic Intake Form Template
Collects contact details, pain and injury history, work and posture information, prior chiropractic experience, and treatment consent for a chiropractor’s new-patient intake.
When to use it
- Before a new patient’s first chiropractic appointment
- When documenting a new pain complaint or injury
- When updating a patient’s work, posture, or activity details
- Before an assessment or treatment that requires consent
What it asks
- What is your full name?
- What is your email address?
- What is your phone number?
- What brings you in today?
- Where are you experiencing pain or discomfort?
- How severe is your pain right now?
- How did the problem start or happen?
- Tell us about your work, daily activities, and posture.
- Have you had chiropractic care before? If so, what was your experience?
- I consent to chiropractic assessment and treatment.
Why it should be encrypted
Pain, injury history, contact details, and treatment consent are personal health information. Encrypting answers in the respondent’s browser helps keep them unreadable to SealForm and people who should not access the intake.
Tips
- Add an optional field for medications or relevant health conditions if your intake process needs it.
- Clarify how patients should describe pain severity, such as using a 0–10 scale.
- Explain how patients can contact your clinic if they have urgent symptoms or need to change an appointment.