TendFormChiropractic Intake Form template
A free chiropractic intake form covering chief complaint, accident details, pain frequency and quality, imaging, red-flag history, and lifestyle. Patients fill it out on their phone before the visit.
Chiropractic Intake Form
Patient information
Full name *
Date of birth *
Phone number *
Email address *
Occupation
Emergency contact name and phone *
Chief complaint
What is the main reason for your visit? *
When did it start? *
Is this the result of an accident? *
No
Auto accident
Work injury
Sports injury
Fall
Other
Date of accident *
How often do you feel it? *
Constantly (76–100% of the day)
Frequently (51–75%)
Occasionally (26–50%)
Intermittently (0–25%)
How would you describe it? *
Pain level today (0 = none, 10 = worst) *
Does it travel anywhere else?
History
Have you seen a chiropractor before? *
Yes
No
Previous chiropractor and approximate date *
Imaging done for this problem
Do any of these apply to you? *
Past surgeries and major injuries
Current medications
Lifestyle
How many hours a day do you sit? *
Less than 2
2–4
4–8
More than 8
How often do you exercise? *
Daily
3–5 times a week
1–2 times a week
Rarely
Stress level (0 = none, 10 = extreme) *
Signature
The information above is accurate to the best of my knowledge *
Yes
No
Signature — type your full legal name *
Date signed *
8 must-ask questions on a chiropractic intake
- Chief complaint
- Accident or injury details
- How often it hurts
- What the pain feels like
- Prior chiropractic care
- Imaging already done
- Red flags like osteoporosis
- Sitting and exercise habits
What's included
- Full name
- Date of birth
- Phone number
- Email address
- Occupation
- Emergency contact name and phone
- What is the main reason for your visit?
- When did it start?
- Is this the result of an accident?
- Date of accident
- How often do you feel it?
- How would you describe it?
- Pain level today (0 = none, 10 = worst)
- Does it travel anywhere else?
- Have you seen a chiropractor before?
- Previous chiropractor and approximate date
- Imaging done for this problem
- Do any of these apply to you?
- Past surgeries and major injuries
- Current medications
- How many hours a day do you sit?
- How often do you exercise?
- Stress level (0 = none, 10 = extreme)
- The information above is accurate to the best of my knowledge
- Signature — type your full legal name
- Date signed
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This template is a starting point, not legal or medical advice, and using it does not by itself make your practice HIPAA compliant. To collect patient health information on TendForm, use the HIPAA plan with a signed Business Associate Agreement, and have your own counsel review consent and policy wording.