Free Chiropractic Clinic Patient Intake Form Template
Chiropractic Clinic Patient Intake Form
Please fill in all the information as accurately as possible.
Name
Date of Birth
Gender
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Male
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Female
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Contact Number
Home Address
Reason for Visit
When did this issue begin?
Describe the pain or symptoms
Check all that apply
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Sharp
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Throbbing
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Burning
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Numbness
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Pain Scale
Rate the pain on a scale from 1 (mild) to 10 (severe):
What activities worsen the pain?
What activities relieve the pain?
Please list your medical conditions you may have:
Are you currently taking any medications or supplements?
If yes, please list:
Consent and Acknowledgment
I certify that the information provided above is accurate and complete. I consent to chiropractic evaluation and treatment as deemed necessary by the clinic.
Name:
Date:
Thank you for your submission!
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