Client Intake Form for Online Chiropractic Consultation

First Name

Last Name

Date of Birth

Gender

Email Address

Phone Number

Street Address

City/Suburb

State/Province

Postal/Zip Code

Preferred Method of Communication

Have you previously received chiropractic care?

If yes, please describe:

Do you have any diagnosed medical conditions?

If yes, please list:

Are you currently taking any medications or supplements?

If yes, please list:

Have you had any recent surgeries or hospitalizations?

If yes, please describe:

Do you have any allergies (e.g., medications, foods, environmental)?

If yes, please list:

Do you have a history of any of the following? (Check all that apply)

What is the primary reason for seeking chiropractic consultation?

How long have you been experiencing this issue?

Rate the severity of your pain/discomfort on a scale of 1-10 (1 = mild, 10 = severe):

Are there any activities or positions that worsen your symptoms?

If yes, please describe:

Are there any activities or positions that improve your symptoms?

If yes, please describe:

Have you tried any treatments or therapies for this issue?

If yes, please describe:

What is your occupation?

Do you have a physically demanding job?

How often do you exercise?

Do you smoke or use tobacco products?

Do you consume alcohol?

If yes, how often?

How would you describe your stress levels?

Do you have access to a reliable internet connection and a device for video calls?

Are you comfortable with receiving advice and guidance remotely without in-person physical adjustments?

Do you understand that online consultations may have limitations compared to in-person visits?

Are you seeking the following from this consultation? (Check all that apply)

Do you have any concerns or questions about online chiropractic consultations?

If yes, please describe:

I understand that the information provided will be used to assess my suitability for online chiropractic consultations and to provide personalized recommendations.

I acknowledge that online consultations are not a substitute for in-person medical care and that I should seek immediate medical attention if I experience severe symptoms or emergencies.

I consent to the chiropractor recording and storing my information securely in accordance with privacy laws.

Client Signature