Chiropractic Patient Intake

About this form

The chiropractic patient intake is a patient intake document used by chiropractic practices. New chiropractic patient intake including chief complaint, pain scale, and goals. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 12 fields:

• Patient Name — Text
• Date of Birth — Date
• Phone — Text
• Email — Text
• Chief complaint / area of pain — Long answer
• Pain scale — Single choice
• When did the pain start? — Text
• How did the injury occur? — Long answer
• Goals for care — Long answer
• Have you seen a chiropractor before? — Single choice
• Signature — Signature
• Date — Date

When practices use it

Chiropractic teams typically attach this form to the new-patient workflow, sending it before the first appointment so the front desk has complete records on arrival. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.