Chiropractic Intake Form
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Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
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Identify as
Occupation
Contact Info
Mobile Phone
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Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
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American Samoa
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Anguilla
Antarctica
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Bouvet Island
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Burkina Faso
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Central African Republic
Chad
Chile
China
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Colombia
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Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
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French Guiana
French Polynesia
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Gabon
Gambia
Georgia
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Gibraltar
Greece
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Grenada
Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
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Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Korea, Republic Of
Kosovo
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Lao People'S Democratic Republic
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Lebanon
Lesotho
Liberia
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Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
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Montserrat
Morocco
Mozambique
Myanmar
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Netherlands
Netherlands Antilles
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Nicaragua
Niger
Nigeria
Niue
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Norway
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Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Health History
Current Health History
What is your height?
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What is your weight?
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What is your main complaint?
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What is your pain level of the complaint above?
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1
2
3
4
5
6
7
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9
10
No Pain
Severe Pain
List if the pain is: Sharp, Dull, Numb/Tingling, Radiating, Inflamed/Swollen, Constant or Intermittent
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What is your secondary complaint?
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What your pain level of the complaint above?
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1
2
3
4
5
6
7
8
9
10
No Pain
Severe Pain
List if the pain is: Sharp, Dull, Numb/Tingling, Radiating, Inflamed/Swollen, Constant or Intermittent
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Please list any other complaints.
Please list any heath care professionals you have seen for this/these condition(s).
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Have you experienced any significant traumas, broken bones, dislocations, or hospitalizations? If so, when?
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Have you recently experienced any of the following:
Nausea/vomiting
Double Vision
Difficulty Speaking/Swallowing
Fainting/Dizziness
Abnormal Numbness/Weakness
None of the above
Have you ever had Chiropractic Treatment before?
Yes
No
If yes how long has it been since your last treatment?
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Females Only, if you are pregnant, how many weeks are you pregnant?
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Medications
Please list current prescriptions or over-the-counter medications
Injuries
Injury
Add Another Injury
Surgeries
Surgery
Add Another Surgery
Past Health History
Head & Neck
Headaches
Stroke
Neck Pain
Vertigo/Dizziness
Seizure Disorder
Mid-back Pain
Chest, Lung, Heart & Skin
Chest Pain
Palpitations
Blood Pressure Issues
Insomnia
Cancer
Night Sweats
Lung Problems
Shortness of Breath
Bruise Easily
Internal, Digestive & Miscellaneous
Nausea
Blood Clots
Bloating
Numbness
Fainting
Anxiety
Abdominal Pain
Liver Problems □
Kidney Problems
Muscle Cramps
Diabetes
Stiff Joints and muscles
Low Energy
Scoliosis
Poor Posture
Review & Agree
Informed Consent To Chiropractic Treatment
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No X-Ray Acknowledgment & Informed Consent
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Explanation of Servics
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*Optional* HIPAA Release Form for Coordinated Care with Gym Staff
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