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Patient Intake Form



Patient Information

Personal Information
Contact Information
Feet Inches



Complaint Information

If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?
What is the reason for this visit?
Date of scheduled appointment
When did this condition begin?
How long have you had this condition?
What caused this condition?
Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.





Upper Extremity

Lower Extremity

Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Review of Systems



Head, Eyes, Ears, Nose and Throat






Dermatological and Bleeding

Past, Family and Social History

List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"

List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.

How would you describe your (or the patient's) personal social habits? Choose all that apply.

How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

Draw Your Symptoms


How did you find out about our office?

Did you hear about our office from an advertisement?

If Yes, Where:


If Yes, Where:

Employment Information

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History

Family/Primary Physician

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Electronic Health Record (EHR) Information

Preferred Language: Ethnicity:
Smoking Status: Smoking Start Date:
Type of Tobacco:
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered


Consent to Office Policy, Treatment, Care and Treadmill Gait and Foot-Strike Analysis: I hereby agree to the Office Policy and I request and consent to the performance of medical services, examinations, chiropractic adjustments and other procedures (including various modes of physiotherapy, Active Release Techniques (A.R.T.) , massage, and diagnostic x-ray) on me (or the patient named below, for whom I am legally responsible for) by the doctors and staff of Colorado Chiropractic & Muscle Care, and/or other licensed clinic doctors or providers working at the clinic. I have had an opportunity to discuss with the doctor and/or with other office staff the nature and purpose of medical services and examinations, chiropractic adjustments, and other procedures. I authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and I also understand my responsibility to inform this office of any changes in my medical status. I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of my treatment for my present condition and for any future condition(s) for which I seek treatment. I consent to treadmill gait and foot-strike analysis and assume all risks involved using a treadmill. I will ask for and accept instructions if I need help using the treadmill.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


Finalizing Form

  1. Submit Form!