Zapof

Chiropractic New Patient Form

Date

I. Patient Information

First Name

Last Name

Date of Birth

Gender

Contact Information

Street Address

City

State/Province

Postal/Zip Code

Phone Number (Primary)

Phone Number (Secondary)

Email Address

Emergency Contact

First Name

Last Name

Phone Number

Relationship

How did you hear about us?

II. Health History

Primary Reason for Seeking Chiropractic Care:

When did your current symptoms begin?

Please describe your symptoms: (e.g., pain location, intensity, frequency, radiating pain, numbness, tingling)

Have you had any previous chiropractic care?

If yes, when and where?

What were the results?

Have you had any other medical treatments for your current condition?

If yes, please describe:

List any current medications (prescription, over-the-counter, supplements):

List any known allergies:

Have you had any surgeries or hospitalizations?

If yes, please describe:

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

Arthritis

Osteoporosis

Disc Herniation/Bulge

Spinal Stenosis

Spondylolisthesis

Fractures (past or present)

Cancer

Heart Conditions

High Blood Pressure

Diabetes

Neurological Disorders

Pregnancy

Other:

If you select "Pregnancy", please enter the gestation age:

Have you experienced any recent trauma (e.g., car accident, fall)?

If yes, please describe:

III. Lifestyle and Habits

Occupation:

Typical Daily Activities:

Do you engage in regular exercise?

If yes, please describe:

Do you smoke?

Do you consume alcohol?

If yes how often?

Do you have any dietary restrictions or preferences?

If yes, please list:

How would you rate your stress level?

Low

Moderate

High

How many hours of sleep do you get per night?

IV. Treatment Suitability Assessment

Please indicate your interest in the following treatments: (Check all that apply)

Spinal Adjustments/Manipulation

Soft Tissue Therapy (Massage, Myofascial Release)

Therapeutic Exercise/Rehabilitation

Postural Analysis and Correction

Nutritional Counseling

Cold Laser Therapy

Electrical Muscle Stimulation (EMS)

Ultrasound Therapy

Decompression Therapy

Instrument Assisted Soft Tissue Mobilization (IASTM)

Are you comfortable with manual adjustments/manipulations?

If no, please explain:

Do you have any concerns or questions about the proposed treatments?

Are you currently experiencing any acute pain or inflammation?

If yes, where?

Do you have any metal implants or pacemakers?

If yes, where?

Have you ever had a negative reaction to any physical therapy or chiropractic treatment?

If yes, please describe:

Are you currently taking any blood thinners?

V. Consent and Acknowledgement:

I understand that the information provided in this form will be used to assess my health and determine the most appropriate course of treatment.

I consent to the collection and use of my personal health information in accordance with HIPAA and other applicable privacy laws.

I understand that chiropractic care may involve risks and benefits, and I have had the opportunity to ask questions and receive satisfactory answers.

I authorize the chiropractor to perform necessary examinations and treatments.

Patient Signature:

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Important Considerations:

  • This form is a template and can be adjusted to fit your specific practice needs.
  • Always comply with local and national privacy laws (e.g., HIPAA in the United States).
  • Ensure patients understand the risks and benefits of each treatment option.
  • Maintain thorough records of patient information and treatment plans.
  • It is always best to consult with a legal professional to ensure your form is compliant with all applicable laws.

Let's break down the detailed insights into this comprehensive client intake form, section by section:


1. Patient Information (Demographics):

  • Purpose:
    Establishes basic identification and contact details for the patient.
    Essential for record-keeping, billing, and communication.
    Emergency contact information is crucial for unexpected situations.
  • Insights:
    "How did you hear about us?" provides valuable marketing data.
    Accurate contact information is vital for follow-up appointments and patient communication.
    Gathering date of birth is important for age-related considerations in treatment.

2. Health History:

  • Purpose:
    Gathers a comprehensive overview of the patient's current condition and past medical history.
    Identifies potential contraindications to chiropractic treatment.
    Helps the chiropractor understand the root cause of the patient's symptoms.
  • Insights:
    Detailed symptom descriptions are critical for diagnosis.
    Previous treatment history (chiropractic or medical) provides context for current care.
    Medication and allergy information is crucial for safety.
    Specific conditions (arthritis, osteoporosis, etc.) require careful consideration during treatment planning.
    Trauma history is very important, as it can be the root cause of many issues.
  • Key Importance: This section is the most important, as it allows the Chiropractor to determine if they can safely and properly treat the patient.

3. Lifestyle and Habits:

  • Purpose:
    Provides insight into factors that may contribute to or exacerbate the patient's condition.
    Allows the chiropractor to offer lifestyle recommendations for improved health.
    Reveals potential stressors that may affect the patient's well-being.
  • Insights:
    Occupation and daily activities reveal potential ergonomic issues.
    Exercise and dietary habits impact overall health and recovery.
    Stress and sleep patterns influence pain perception and healing.
    Alcohol and tobacco usage can affect healing.

4. Treatment Suitability Assessment:

  • Purpose:
    Gauges the patient's comfort level and interest in various treatment options.
    Identifies potential contraindications to specific therapies.
    Facilitates informed consent and shared decision-making.
  • Insights:
    Patient preferences are essential for a positive treatment experience.
    Concerns about manual adjustments should be addressed thoroughly.
    Acute pain, metal implants, and blood thinners require careful evaluation.
    This section allows the patient to have a say in their treatment, and allows the chiropractor to know what treatments the patient is comfortable with.
  • Key Importance: This is important for informed consent, and for patient comfort.

5. Consent and Acknowledgement:

  • Purpose:
    Ensures the patient understands the purpose of the intake form and the nature of chiropractic care.
    Obtains informed consent for examination and treatment.
    Protects the chiropractor from liability.
  • Insights:
    Patient signature confirms understanding and agreement.
    Chiropractor signature validates the intake process.
    This section is legally important.

6. Additional Notes (For Chiropractor Use):

  • Purpose:
    Provides space for the chiropractor to record observations, findings, and treatment plans.
    Facilitates continuity of care and accurate record-keeping.
  • Insights:
    This section allows for personalized notes and documentation.
    It serves as a valuable resource for future appointments.

Overall Insights and Considerations:

  • Comprehensive Data Collection: The form aims to gather a holistic view of the patient's health and lifestyle.
  • Patient-Centered Approach: It encourages patient participation and addresses their concerns.
  • Risk Management: It identifies potential contraindications and ensures patient safety.
  • Legal Compliance: It includes consent and acknowledgment sections to protect the practice.
  • Customization: Chiropractors should adapt the form to their specific practice and patient population.
  • Digitalization: Many practices are moving towards digital intake forms for efficiency and data management.
  • Regular Review: The form should be reviewed and updated periodically to reflect current best practices.

By carefully analyzing the information provided in this intake form, chiropractors can develop personalized treatment plans and provide optimal care to their patients.


To configure an element, select it on the form.

To add a new question or element, click the Question & Element button in the vertical toolbar on the left.