Chiropractic Intake Form Page 2
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4Your health profile:
What is the reason for
How/when did your
your appointment?
condition start
Is your condition
Better
Please describe:
getting better or
Worse
worse?
What aggravates your
condition?
What makes it feel
Have you had a
No
better?
similar problem
Yes
before?
Were you injured at
No
Has your employer
No
work?
been notified?
Yes
Yes
Were you injured in a
No
Date of accident:
vehicle accident?
Yes
List any tests or x-
rays/MRI/CT you've
had for your condition:
List any previous
surgeries, illnesses,
fractures or injuries:
List any allergies:
Have you seen a
No
Last visit?
Chiropractor before?
Yes
Family Doctor name:
Last physical date?
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