Chiropractic Intake Form — shared by the community
Tom H. shared this 19-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 19 questions, 2 pages, 3 conditional rules.
- Shared by
- Tom H. · Agency owner
- Questions
- 19
- Replies
- 4
- Copies taken
- 517
chiropractic intake form, chiropractic new patient form template, chiropractor patient form online, spinal intake form, manual therapy intake form, chiropractic consent form, chiropractic intake, chiropractic intake forms, chiropractic intake template, online chiropractic intake, chiropractic, chiropractics, intake, intakes, patient, complaint, history, previous, patient intake form, medical intake, clinic form, new patient form, referral form, health questionnaire, patient registration, clinical form, symptom screening, medical history form, chiropractic intake form example, shared chiropractic intake form
Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 2 — Your complaint
This template runs as a straight sequence — no branching rules.
Works for you? Take Tom H.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Chiropractic Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 19 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It records a signature you can keep as proof of agreement.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Chiropractic Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “Have you had chiropractic or manual treatment before?” is Yes, “How did you respond to it?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Any accident, fall or collision in the last year?” is Yes, “What happened, and when?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Have you been advised to avoid any movements?” is Yes, “What were you advised to avoid?” becomes mandatory before the form can be sent.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — Your complaint
- Full namerequired
- Date of birthrequired
- Contact numberrequired
- Main area of complaintrequired
- When did it begin?required
- How does it behave?required
- Does it spread anywhere else?required
- What have you already tried?
Page 2 — Health and consent
- Have you had chiropractic or manual treatment before?required
- How did you respond to it?
- Current medication
- Any accident, fall or collision in the last year?required
- What happened, and when?
- Previous surgery to this area
- Have you been advised to avoid any movements?required
- What were you advised to avoid?
- Anything you are anxious about
- Consentrequired
- Signaturerequired
Conditional logic in this build
- When “Have you had chiropractic or manual treatment before?” is Yes, require “How did you respond to it?”.
- When “Any accident, fall or collision in the last year?” is Yes, require “What happened, and when?”.
- When “Have you been advised to avoid any movements?” is Yes, require “What were you advised to avoid?”.
Questions about this shared form
Do we still need a separate consent form?
This form records consent to examination and treatment as discussed. Where a specific technique warrants its own conversation, document that with the Consent to Treatment Form as well.
How is it different from the Physiotherapy Intake Form?
That one is built around activity goals and rehabilitation progress. This one asks more about manual treatment history, referral of symptoms and prior advice to avoid movements.
Can it be completed at reception?
It can, but the health section is the part that suffers under time pressure, so send it ahead where the appointment allows.
Is a signature required?
Keep it. The consent question and the signature together are what make the record defensible if the treatment is ever queried.
Is the Chiropractic Intake Form template free to use?
Yes. You can preview and test Chiropractic Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Chiropractic Intake Form template ask for?
It asks 19 questions across 2 pages, 12 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Chiropractic Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Have you had chiropractic or manual treatment before?” is Yes, “How did you respond to it?” becomes mandatory before the form can be sent. Features conditional validation: if “Any accident, fall or collision in the last year?” is Yes, “What happened, and when?” becomes mandatory before the form can be sent. Features conditional validation: if “Have you been advised to avoid any movements?” is Yes, “What were you advised to avoid?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Chiropractic Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Chiropractic Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Is the signature on this form legally usable?
The template captures a drawn signature and stores it with the submission, along with the timestamp, so you keep evidence of who agreed and when. Whether that is sufficient depends on your jurisdiction and the agreement itself.
More from the community
Quick Patient Check-In
One-screen arrival form for the waiting room: identity confirmed, reason for the visit noted, and any change since the last visit flagged for the clinician.
Quick Symptom Report
Short between-appointments update: what the patient is noticing now, since when, how it is affecting daily life and whether they want a call.
Quick Refill Request
Single-screen repeat prescription request with medication and dose, preferred pharmacy, collection or delivery and a note for the prescriber.
Quick Cancellation Form
A fast way for patients to cancel or move an appointment, with the slot details, a short reason, and whether they want to be offered another time.
Quick Clinic Feedback
Two-minute post-visit feedback form covering booking, waiting, the consultation itself and whether the patient left knowing what happens next.
Quick Vaccination Record
Short record of a vaccination given: patient, product and batch number, site and date, plus who administered it and any observation in the minutes after.