What is the chiropractic intake form template?
The first chiropractic visit needs a lot of background: where it hurts, how it started, whether pain travels into the arms or legs, what's been tried, and — critically — any conditions that change which techniques are appropriate, such as osteoporosis, a clotting disorder or a history of stroke.
This template collects all of it in five short pages. Pain areas, frequency and a 0–10 scale describe the complaint; car accidents and work injuries ask for claim details; pain that spreads asks where. A required health-history checklist makes sure the conditions that matter for treatment are always answered.
Each intake, with its signed consent and any scan reports, is saved as a PDF in the vault folder you choose.
- Best for
- Chiropractic clinics and multidisciplinary spine practices
- Filled in by
- The patient, or a parent or guardian for a child
- Time to complete
- About 8 minutes
- Includes
- Pain-area checklist, cause with claim follow-ups, pain scale, previous care, scan uploads, health checklist, informed consent
Who uses a chiropractic intake form?
- New-patient paperwork sent with the booking confirmation
- Car accident patients who need claim details on file
- Work injury patients referred by employers
- Tablet check-in for walk-in or same-day patients
- Clinics replacing clipboards and scanned paper forms
- Returning patients presenting with a new complaint
Questions on this chiropractic intake form
33 questions over 5 pages · includes signature, file upload, conditional questions, multiple pages, consent checkbox, ratings.
1 About you
- Your full name*
- Date of birth*
- Gender Female · Male · Non-binary · Prefer to self-describe · Prefer not to say
- Mobile phone*
- Email*
- Home address
- Occupation
- Emergency contact name*
- Emergency contact phone*
2 Your complaint
- Main complaint*
- Where do you have pain or discomfort?* Head or headaches · Neck · Shoulders · Mid back · Lower back · Hips or pelvis · Arms or hands · Legs or feet · Jaw
- When did it start?
- What caused it?* Car accident · Work injury · Sports injury · A fall · No specific cause
- Claim number and insurer asked only when it applies
- Employer and claim number asked only when it applies
- How often do you feel it?* Constantly · Most of the day · A few times a day or week · It comes and goes
- Pain right now
- Does the pain spread into your arms or legs?*
- Where does it spread, and does it cause numbness or tingling?* asked only when it applies
- What does it make difficult? Sleep · Work · Driving · Sitting · Standing · Exercise · Lifting · Household chores
3 Previous care
- Have you seen a chiropractor before?*
- When, and for what? asked only when it applies
- Other treatment you've had for this problem Doctor or GP · Physiotherapy · Massage · Acupuncture · Medication · Injections · Surgery · None yet
- Have you had X-rays, MRI or other scans of your spine or joints?*
- Scan reports asked only when it applies
4 Health history
- Do you have, or have you had, any of these?* Osteoporosis or low bone density · Arthritis · A recent fracture · Stroke or mini-stroke (TIA) · A blood-clotting disorder or blood-thinning medicine · Cancer, now or in the past · Heart condition or high blood pressure · Spinal surgery or joint replacement · Current pregnancy · None of these
- Medications you take
- Operations, serious illnesses or accidents
5 Consent
- Consent to examination*
- Consent to treatment*
- Privacy and accuracy*
- Signature*
- Date*
The chiropractic intake form, page by page
1 About you
Name, date of birth, mobile, email and an emergency contact are required. Gender, address and occupation are optional.
2 Your complaint
The patient describes the main complaint and ticks at least one pain area, from headaches to legs and feet. They give when it started and what caused it; a car accident asks for claim details and a work injury for the employer and claim number. Frequency is required, pain now is on a 0–10 scale, and a required question asks whether pain spreads into the arms or legs — yes asks where and whether there's numbness or tingling. A checklist records what the pain makes difficult.
3 Previous care
Required questions ask whether they've seen a chiropractor before and whether they've had scans; scans can be uploaded (up to five files). A checklist records other treatment already tried.
4 Health history
A required checklist covers conditions relevant to chiropractic care — osteoporosis, arthritis, recent fractures, stroke or TIA, clotting disorders or blood thinners, cancer, heart conditions, spinal surgery or joint replacement, pregnancy — or none. Medications and past operations are optional.
5 Consent
An informed-consent paragraph explains what care may involve and that soreness is common and serious complications rare, with a note to replace it with your own wording. Three consents cover examination, treatment and privacy, followed by signature and date.
Make the template yours
- Replace the informed-consent paragraph with your clinic's approved wording
- Add your payment and insurance questions if you bill insurers
- Add a question on how the patient heard about the clinic, if you track referral sources
- Add outcome measures your clinic uses, such as a disability index, as extra questions
- Send it with booking confirmations so it's complete before arrival
- Route intakes to a folder per practitioner
Tips for a better chiropractic intake form
- Read the health-history answers before the examination, not after
- Follow up on any radiating pain with numbness or weakness carefully
- Ask for scan reports rather than just the images when possible
- Re-confirm consent verbally before the first adjustment
- Keep intakes in a restricted clinical folder
- Check your consent wording with your professional body or regulator — this template isn't legal advice
Every response becomes a PDF in your vault
Each intake is filed as a signed PDF in your chosen vault folder, with scan reports attached. The clinic is notified and the patient receives a copy by email.
Use the Responses table to prepare for the day's new patients, filter by cause to find accident or work-injury cases, or export to CSV for your practice-management system.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Chiropractic intake form: frequently asked questions
Is this chiropractic intake template free to use?
Yes. It's one of FileIt's ready-made templates, and every FileIt account, including the free plan, includes the Forms app and its full library of templates.
Do patients need a FileIt account to fill it in?
No. Patients complete it from a link or emailed request without creating an account. Only the clinic needs one.
Why is the health-history checklist required?
Some conditions, such as osteoporosis or clotting disorders, affect which techniques are appropriate. Requiring an answer — including "none of these" — makes sure it's never skipped.
Can patients upload X-ray or MRI reports?
Yes. Patients who say they've had scans can upload up to five reports as PDFs or photos.
Can I add accident claim questions?
The form already asks for claim details when the cause is a car accident or work injury. You can add more questions in the designer.
Is the informed-consent wording ready to use?
No — it's a placeholder to replace with your clinic's own wording, checked against your professional and legal requirements.