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Adult Patient Intake Form

Male Female






Existing Patient


Another Provider

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Post Injury

Front of head Right side of head

Back of head Left side of head

Front of neck Right side of neck

Back of neck Left side of neck

Right mid back Central mid back

Left mid back

Right low back Central low back

Left low back

Abdomen Back of ribs

Chest Right side of ribs

Front of ribs Left side of ribs

Front of right upper extremity Front of Left upper extremity

Rear of right upper extremity Rear of Left upper extremity

Front of right shoulder Front of left shoulder

Rear of right shoudler Rear of Left upper shoulder

Front of right upper arm Front of left upper arm

Rear of right upper arm Rear of Left upper arm

Front of right elbow Front of left elbow

Rear of right elbow Rear of Left elbow

Front of right wrist Front of left wrist

Rear of right Wrist Rear of Left wrist

Front of right hand Front of left hand

Rear of right hand Rear of Left hand

Front of right lower leg Front of left lower leg

Rear of right lower leg Rear of left lower led

Front of right hip Front of left hip

Rear of right hip Rear of left hip

Front of right thigh Front of right knee

Rear of right thigh Rear of right knee

Front of left thigh Front of left knee

Rear of left thigh Rear of left knee

Front of right leg Front of right ankle

Rear of right leg Rear of right ankle

Front of left leg Front of left ankle

Rear of left leg Rear of left Ankle

Front of right leg Front of right ankle

Rear of right leg Rear of right ankle

Front of left leg Front of left ankle

Rear of left leg Rear of left Ankle

Top of right foot Top of left foot

Bottom of right foot Bottom of left foot

Right of right foot Right of left foot

Left of right foot Left of left foot

Yes No

Aching Sharp

Annoying Shock-like

Burning Shooting

Deep Stabbing

Diffuse Stiffness

Dull Throbbing

Heavy Tightness

Intolerable Tingling

Pulling OTHER

Gradual Insidious Recent Spontaneous Sudden Traumatic Unknown

Mild Mild to moderate Moderate Moderate to severe Severe

1 2 3 4 5 6 7 8 9 10

Least severe <------------------------------>Most severe

Constant Frequent Intermittent On and off Random Recurring



Social Life






Travelling or Driving

Personal Care

Almost any movement Love life

Athletic activity and/or exercise Lying down

Bathing Pulling

Bending Pushing

Caring for family Reaching

Carrying Reading

Changing positions Repetitive motions

Climbing stairs Resting

Computer use Running

Concentrating Self care(dressing, bathing, etc.)

Cooking Shaving

Coughing and/or sneezing Sitting

Daily Child or pet care Squatting

Driving Standing

Eating Stress

Falling or staying asleep Stretching

Getting in or out car Talking on telephone

Getting out of bed Turning

Getting up from lying down Twisting

Getting up from sitting Unknown

Grocery shopping Walking

Household chores Working

Lifting Yard work

Looking over shoulder OTHER

Nothing Prescription medication Chiropractic adjustment

Re-direct attention Cold packs

Excercise Rest

Heat packs Stretching

Massage Work

Over-the-counter medications OTHER

Physical therapy


Acupuncture Occupational therapy

Chiropractic care Osteopathic medicine

Craniosacral therapy Over-the-counter medications

Homeopathic medicine Physical therapy

Hypnosis Prescribed medications

Injection therapy Psychotherapy

Medical care Reiki

Naturopathic medicine Surgery

Nutritional supplements OTHER

Yes No Unsure

Yes No

Bending over Looking over shoulder

Caring for family Love life

Climbing stairs Lying down

Concentrating Reaching overhead

Dressing myself Rising out of chair or bed

Driving a car Showering or bathing

Excercising Sitting

Getting in/out of car Standing

Getting to sleep Staying asleep

Grocery shopping Using a computer

Household chores Walking

Lifting objects Yard work


Yes No

TRAUMAS:Physical Injury History

Yes No

Yes No

Yes No

Yes No

None 1-2 x per week 3-6 x per week Daily

Back Side Stomach

Refreshed and ready Stiff and tired


Yes No

Yes No

Yes No

Yes No

Yes No

TOXINS: Chemical & Environmental Exposure

Please rate your CONSUMPTION for each where 0 is none and 5 is high:

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

THOUGHTS: Emotional Stresses & Challenges

Please rate your STRESS for each where 0 is none and 5 is high:

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5



Resolve existing condition(s) Overall wellness Both

Yes No

Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other


Yes No


Personal Insurance No Insurance Self Pay

Primary Insurance


I certify that I'm the patient listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment at the time services are rendered.