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Chiropractic Intake Form
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Section 1: Who Are You?
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Email (for communication w/ doctor only):
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Join our mailing List?
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Occupation
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How did you hear about us?
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Other
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Section 2: How Can We Help?
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What is the primary reason for your visit?
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What are your primary goals?
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Any specific goals? I want to be able to
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Have you seen a chiropractor?
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Date of last visit?
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Additional goals you are interested in?
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Other
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Section 3: Tell us About your Primary Issue
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How long ago did it begin?
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Was this a result of a car accident or accident at work?
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If not, was there a known cause?
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Is there anything that makes it better?
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Other
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Is there anything that makes it worse?
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Other
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Have you seen other practitioners for this?
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Does the discomfort refer / travel anyplace else?
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where?
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How intense is the discomfort? (check multiple if it varies)
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How often do you feel it?
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hours per day
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days per week
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days per month
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Section 4: About Your Health
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Height:
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Weight:
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Blood pressure (if known):
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Tobacco usage
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day/week/mo
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Alcohol usage
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day/week/mo
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Current medications or treatments:
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ALL known allergies, drug or common:
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Past surgeries and approximate dates:
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History of major trauma or illness:
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Current or past issues with the following body systems:
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Eyes
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Please describe
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Ears
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Please describe
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Nose
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Please describe
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Throat
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Please describe
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Skin
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Please describe
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Hair
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Please describe
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Nails
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Please describe
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Bones
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Please describe
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Joint
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Please describe
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Heart
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Please describe
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Lung
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Please describe
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Digestive system
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Please describe
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Nervous system
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Please describe
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Vascular system
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Please describe
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Urinary system
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Please describe
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Respiratory system
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Please describe
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Urinary system
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Please describe
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Endocrine system
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Please describe
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Reproductive system
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Please describe
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Diabetes
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Please describe
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Neuropathy
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Please describe
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Osteoporosis/penia
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Please describe
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At times we may be having direct contact with you skin during examination and treatment.
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Have any condition which is communicable through skin-on-skin contact or any other blood borne condition?
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Acupuncture Intake
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Section 1: Who Are You?
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Email (for communication w/ doctor only):
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Join our mailing List?
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Have you been treated by Acupuncture before
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Occupation
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Marital Status
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Children? Number/Ages
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How did you hear about us?
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Who can we thank for the referral?
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Section 2: How Can We Help?
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Complaint(s) / Concern(s)
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Primary Complaints / Concerns
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When Did This Start
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Heat Makes It
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Cold Makes It
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Damp Weather Makes It
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Exercise/Activity Makes It
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Other (please specify)
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Other Makes It
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Secondary Complaints / Concerns
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When Did This Start
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Heat Makes It
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Cold Makes It
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Damp Weather Makes It
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Exercise/Activity Makes It
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Other please specify
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Other Makes It
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Additional Complaints / Concerns
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Musculoskeletal Pain and Discomfort
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Areas of Discomfort
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Head
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Amount of pain
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Neck
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Amount of pain
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Jaw
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Amount of pain
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Shoulder
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Amount of pain
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Arm
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Amount of pain
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Elbow
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Amount of pain
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Wrist
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Amount of pain
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Hand
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Amount of pain
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Upper back
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Amount of pain
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Chest
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Amount of pain
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Abdomen
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Amount of pain
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Lower back
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Amount of pain
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Hip
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Amount of pain
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Thigh
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Amount of pain
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Knee
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Amount of pain
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Ankle
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Amount of pain
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Other please specify
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Amount of pain
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Medical History
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Have you seen a physician in the last year
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If yes please explain
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Physician’s name
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Approximate date of most recent exam/visit?
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Past or Current Conditions
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Cancer
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Type
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When
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Hepatitis
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High blood pressure
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Hormonal Endocrine Disorders
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Type
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When
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Rheumatic fever
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When
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Infectious diseases
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Type
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When
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Diabetes
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Type
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When
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Heart disease
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Type
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When
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Seizures
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Type
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When
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Autoimmune disorders
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Type
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When
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Emotional disorders
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Type
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When
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Tuberculosis
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When
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Sexually transmitted diseases
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Type
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When
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Usage and Frequency of the Following
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Coffee/black tea
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Amount
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Recreational drugs
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Amount
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Tobacco
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Amount
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Alcohol
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Amount
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Soda
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Amount
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Binge eating
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Amount
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Are you in recovery? Sober since
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Would you like support on cutting back on any addictive habits
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Do you have a special diet now or in the past
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I have a pacemaker
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I have known allergies
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If yes, please list the allergies
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I am taking lithium (Eskalith, LIthobid, Lithonate, Lithotabs)
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I am taking Coumadin/Warfarin/Plavix
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Do you exercise regularly
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If so, what
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Major Surgeries or Hospitalizations
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How Often
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Other Illnesses or Injuries
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When
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Current Medications
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Reason for intake
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Dosage
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Rx/Supplement/Herbs
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Reason for intake
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Lifestyle Stresses or Concerns
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Body Systems Assessment
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How warm/cold do you feel (not in degrees) relative to other people? 1 being cold and 10 being hot
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Pick the symptoms you have with temparature
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If picked unusual sweats is it on AM/PM
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Where on body (Sweat)
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Your overall body moisture (hair, skin, mouth, bowels, etc.)
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Your overall body moisture (hair, skin, mouth, bowels, etc.)
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Pick the symptoms you have with moisture
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Please specify Edema/swelling in which part of the body
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Digestion Score 1 being Diarrhea and 10 being Constipation
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Bowel Movements: How often?
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Stools keep shape
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Pick the symptoms you have with digestion
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Energy level 1 being Low and 10 being High
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Pick the symptoms you have with energy
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Please specify the time of sudden energy drop
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Please specify headaches _____/Wk
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Hours of sleep per night
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Sleep Difficulty
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Wake ___x night
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@_____ (am/pm)
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Wake to urinate, How often?
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Disturbing Dreams
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Restless sleep
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Groggy upon waking
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Please specify the color of Phlegm
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Eyes, Ears, Nose, Throat
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Emotions
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Urinary Issues
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Female Health
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Age of 1st Period (menarche)
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Are you pregnant
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# of pregnancies
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Age of last period (menopause)
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# of live births
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# of abortions
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# of miscarriages
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Number of days between periods
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Number of days of flow
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Flow
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Date of last: Gynecologic exam
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Pap Smear
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Bone Density scan
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Mammogram
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Male Health
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Date of last prostate check up
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PSA results
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Manual prostate exam results
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Lab results
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Frequency of Urination
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Color of urine
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Anything else you would like us to know?
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Amount
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Type
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When
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Additional Free Field Notes
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Color of urine
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Odor
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Symptoms related to prostate
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Other please specify
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Anything else you would like us to know?
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Massage Intake Form
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Have you had professional massage / bodywork before?
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When was the last time?
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Current pregnancy or breast feeding
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List any previously broken bones
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List any previous neck or spinal injuries
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List any allergies
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Are you diabetic?
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Are you diabetic?
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List any swollen joints
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Headache frequency
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Do you have sinus issues?
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Are you diabetic?
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List any areas of arthritis
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Do you have epilepsy or seizures?
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Do you have osteoporosis?
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Do you have high blood pressure?
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Do you have claustrophobia?
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Do you have varicose veins?
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List any conditions being treated by a physician, chiropractor, or therapist
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List any current medicantions
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List current communicable / contagious diseases
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Do you have heart disease?
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Do you have asthma or respiratory issues?
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List any recent surgeries
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List any joint replacements
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List any cardiac issues
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List any pins, plates, or wires
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Current stress level
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Current neck or back pain
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Current areas of numbness / tingling
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Current areas sensitive to touch
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List any areas you do not want touched
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Do you bruise easily?
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List any areas of open wounds / sores
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List any significant scars
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Other medical conditions we should be aware of
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List any sensitivity to lotions / essential oils
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Desired results of care
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