Template library · Intake forms
Chiropractic Intake template
Please complete before your first adjustment.
- 17 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- DateDate
- PractitionerText
Contact Info
- Full nameText
- Date of birthDate
- Phone numberText
- EmailText
- Emergency contact (name & phone)Text
Health History
- What brings you in today?Text
- Other (Where do you feel pain or discomfort)Text
- Current pain levelText
- Prior injuries or accidentsText
- Other (Do you have any of the following)Text
- Where do you feel pain or discomfort? (check all that apply):
- Neck
- Upper back
- Lower back
- Shoulders
- Hips
- Legs
- Do you have any of the following? (check all that apply):
- Osteoporosis
- Herniated disc
- Arthritis
- Pregnant
- Previous spine surgery
Lifestyle & Goals
- OccupationText
- Activity levelChoice
- What would you like to achieve from treatment?Text
- Client signatureSignature
- Date signed (client)Date
When to use it
Send an intake form when a new client books, so their history, contact details and reasons for coming are in front of you before the first appointment rather than taken down during it.
How it works in MyWellOps
- Choose it from Documents and adjust the questions to your practice.
- Send it to the client, who completes it in their client portal.
- Their answers are kept on the client’s record, ready for the first session.
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