Templates Health & Wellness Chiropractic Intake Form Template

Chiropractic Intake Form Template

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Personal Information

Full Name

Emergency Contact Details

Contact Name

Primary Health Concern

Selected Value: 7

Health History

Lifestyle Information

Consent for Treatment

I hereby give consent to the chiropractic treatments and procedures.
Clear Signature

The Chiropractic Intake Form Template by WPForms streamlines the intake process and facilitates a patient-centric approach to care.

How Does the Chiropractic Intake Form Template Work?

Designed to be intuitive and in-depth, this form ensures practitioners receive a complete understanding of their patient’s health profiles and specific needs. It comes equipped with many key sections for the intake process, such as:

  • Personal Information: This section helps capture the full name, email address, phone number, date of birth, and gender of the patient. Chiropractic professionals can easily keep records streamlined and personalized, ensuring every patient feels known and valued from the outset.
  • Emergency Contact: We’ve seamlessly integrated an Emergency Contact Details section. Recognizing the importance of safety and the unpredictability of health situations, this inclusion ensures that practitioners have a reliable point of contact should any urgent situation arise.
  • Primary Health Concern: Venturing deeper into the core of patient wellness, the Primary Health Concern segment provides a canvas for patients to detail their reason for the visit, duration of the problem, type of pain, frequency, and overall rating of the pain they’re experiencing to formulate treatment plans accordingly.
  • Health History: By allowing patients to articulate their specific ailments, duration, and discomfort, chiropractors gain deep insights into their concerns. Additionally, understanding a patient’s historical interactions with chiropractic care and any surgical interventions further refines the care approach.
  • Lifestyle Information: Recognizing the intricate relationship between lifestyle and health, our form integrates a Lifestyle Information section. By gathering insights into a patient’s occupation, weekly working hours, and physical activity habits, chiropractors can get a complete picture of the daily stresses and strains.
  • Consent for Treatment: At the foundation of any medical interaction lies trust. Our Consent for Treatment section, fortified with an integrated digital signature capability (exclusive to the WPForms Pro License holders with the Signature Addon), ensures that transparency and patient autonomy are upheld.

Sign up with WPForms today and access our Chiropractic Intake Form Template. By incorporating this template, you optimize the intake process and set the stage for a patient relationship built on trust, understanding, and tailored care.