Chiropractic Patient Intake Form - Dreicer Chiropractic Center

Personal Information and Contact Details

This form can be filled out and saved online. At any time when filling the form, if you can scroll to the bottom and click "Save and Continue Later". After completing the form you can print or save a copy.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Occupation

Work Phone

Home Phone

Cell Phone

Email Address*

Date of Birth*

Please enter you date of birth MM-DD-YYYY

Social Security Number

Gender*

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Student

Yes
No

Health Questions

Have you ever had chiropractic care?

Yes
No

When?

Why?

Where?

Were x-rays taken?

Yes
No

When was your last adjustment?

Check off any allergies

Other allergies (list)

Check off any surgeries

Other surgeries (list)

Check off all past medical history conditions

Other conditions (list)

Check off types of medication you are taking

Anxiety
Muscle Relaxers
Pain Killers
Insulin
Birth Control
Cardiovascular
Allergy
Seizure

Other medications (list)

Check off your family history

Other family history (list)

Have you had any auto or other accidents?

Yes
No

Describe accident(s)

Lifestyle Questions

Date of last physical examination

Do you smoke?

Yes
No

If yes, how many per day

Do you drink alcohol?

Yes
No

If yes, how many per day

Do you drink caffeine?

Yes
No

Do you exercise?

Yes
No

If yes, what forms of exercise and how often?

Reason For Visit

What is your major complaint?

Date problem began

Main reason for consulting office?

Become pain free
Explanation of my condition
Learn how to care for condition
Reduce symptoms
Resume normal activity level

How did this problem begin (falling, lifting, etc.)

How often do you experience your symptoms?

Constantly 76% - 100% of the day
Frequently 51% - 75% of the day
Occasionally 26% - 50% of the day
Intermittently 0% - 25% of the day

How is your condition changing?

Getting better
Getting Worse
Not changing

Have you had condition in the past?

Yes
No

Rate pain from 1 - 10 with 0 = "No pain" and 10 = "excruciating pain"

Describe the nature of your symptoms (check all that apply)

Sharp
Dull
Numb
Burning
Shooting
Tingling
Radiating pain
Stabbing
Throbbing

Other (list)

How do your symptoms affect your ability to perform daily activities such as working or driving?

What activities aggravate your condition? (work, exercise, etc)

What makes your pain feel better? (ice, heat, massage, etc)

Body Pain Chart

Please download and print the attached body chart PDF, then fill it out and bring the form with you to your appointment.
Click to Download Body Form PDF

Do you have a Second Reason for this Visit*

Yes
No

Second Reason for Visit

If you have a second complaint fill out the following

What is your second complaint?