Chiropractic Health Assessment

Patient Information

Full Name *

Date of birth *

Gender

Male

Female

Email *

Phone *

Address

Street Address

City

State

Country

Postal Code

How did you find us?

Primary Health Information

What is the main reason you are seeking care? *

When was the last time you saw a chiropractor? *

Have you been in a recent car accident or traumatic event? *

Approximate date of event

Brief description of what happened

Were you evaluated by another healthcare provider?

Clinical Intake Questions

Is your pain:

Pain Severity

On a scale of -10 (0 = no pain, 10 = worst possible pain)

What makes it better?

What makes it worse?

Have you experienced any of the following neurological symptoms?

Have you had any surgeries? Where and when?

Have you ever had any fractures? Where and when?

Do you have any current medical conditions?

Are you currently taking any medications or supplements?

On average, how many hours do you sleep per night?

How would you rate your current stress level?

On a scale of 0–10 (0 = no stress, 10 = extreme stress)

How often do you exercise?

How would you rate your current energy level?

(0 = extremely low, 10 = excellent)

I consent to chiropractic evaluation and treatment and confirm that the information I have provided is true and accurate to the best of my knowledge.

New Patient Appointment