Chiropractic Client Intake Form

Chiropractic Client Intake Form

Last updated July 17th, 2023

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Chiropractic client intake forms are documents 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’ll assist the chiropractor during the scheduled appointment. By collecting this information beforehand, chiropractors can shorten patient waiting times and get a head start in preparing treatment strategies.

Notice of Privacy Practices

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) obligates most healthcare providers, including chiropractors, to provide patients with a Notice of Privacy Practices. This notice should be made available before or at the initial appointment.


What the Intake Form Includes

Patient Information

Patients will provide personal information, including their name, address, phone number, e-mail, and emergency contact details. Supplying basic employment information can also be helpful, as it allows the chiropractor to identify possible occupational hazards that may impact the patient’s condition.

Medical History

An essential component of the intake form is the patient’s medical history. This section assists the chiropractor in pinpointing immediate health concerns that could impact the treatment results. The medical details included in the form are:

  • Current illness
  • Allergies
  • Past surgeries
  • Lifestyle (e.g., whether the patient smokes or drinks)


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. If the symptoms resulted from a workplace or auto accident, the form should include this information as well.

Family Health

Illnesses, diseases, and other medical issues affecting the patient’s family are also documented in the intake form. This information gives the chiropractor insight into underlying hereditary issues and genetic predispositions that can put the patient’s health at risk.

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.

Benefits of Intake Form for Chiropractors

An intake form is a vital tool for chiropractors and performs several key functions, such as:

  • Standardized Data Collection – Using an intake form, chiropractors establish a system for documenting their patients’ medical conditions, symptoms, habits, and general health.
  • Efficient Consultation – An intake form reduces the number of questions patients need to be asked during their consultation, giving the chiropractor more time to analyze their posture, assess joint and spinal mobility, and perform other physical examinations.
  • Risk Assessment – By reporting preexisting medical conditions, old injuries, and past surgeries, the intake form helps chiropractors recognize possible treatment risks and implement precautions that prioritize patient safety.
  • Treatment Planning – The information obtained from the intake form aids chiropractors in creating customized treatment plans that cater to each patient’s physical limitations and mobility goals.