Chiropractic New Patient Intake and Pain Assessment

Chiropractic New Patient Intake and Pain Assessment — Form Fields

This healthcare template includes 12 fields. Gather health history and pain details from new chiropractic patients before treatment. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Chief Complaint (dropdown selection, required) — options: Neck Pain, Low Back Pain, Mid Back Pain, Headaches, Shoulder Pain, Hip Pain, Other
• When Did the Pain Start? (text, required)
• Onset (dropdown selection, required) — options: Sudden injury, Gradual onset, Recurring condition
• Is the pain constant or intermittent? (multiple choice, required) — options: Constant, Intermittent
• Current Pain Level (1–10) (rating, required)
• Aggravating Factors (checkboxes, optional) — options: Sitting, Standing, Walking, Bending, Lifting, Morning stiffness
• Previous Treatments Tried (long text, optional)
• Have you had chiropractic care before? (dropdown selection, required) — options: Yes – recently, Yes – in the past, Never