Chiropractic Client Intake Form

A chiropractic client intake form is a document that new patients are asked to fill out before their first chiropractic treatment. The purpose of the form is to gather the patient’s contact information, medical history, symptoms, insurance details, and other data that will assist the chiropractor during the scheduled appointment.

Last updated September 30th, 2024

Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires healthcare providers, including chiropractors, to provide patients with a notice of privacy practices (NPP). This notice should be made available before or on the initial appointment date.^[1]

HIPAA Notice of Privacy Practice Sample (for practitioners)

What an Intake Form Includes

Patient Information

The patient must provide personal information, including name, address, phone number, e-mail, and emergency contact details. Basic employment information can also help the chiropractor identify possible occupational hazards.

Insurance Policies

Patients with health insurance will be asked to supply their insurance provider’s name and policy details. Healthcare facilities use this information to determine the extent of the patient’s coverage and establish billing procedures.

Symptoms

The intake form collects detailed information about the patient’s symptoms, such as the location and intensity of pain, the onset of symptoms, and the factors that alleviate or worsen the pain.

Medical History

This section asks for the following information to help the chiropractor pinpoint health concerns that could impact the treatment results:

Current illness
Allergies
Past surgeries
Lifestyle (e.g., smoking, drinking, drugs)

Family History

The patient should outline any illnesses, diseases, and other medical issues that have affected their family members.