Chiropractic Intake Form
New patient intake for chiropractic care: the complaint and its history, previous manual treatment, general health screening, and consent to treat.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 19 questions, 2 pages, 3 conditional rules.
- Questions
- 19
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 6 min
- Conditional rules
- 3
Searches this template answers
- chiropractic intake form
- chiropractic new patient form template
- chiropractor patient form online
- spinal intake form
- manual therapy intake form
- chiropractic consent form
Also filed under
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.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
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.
About this template
Chiropractic first appointments involve an examination, so the paperwork needs to arrive beforehand and needs to cover more than the presenting complaint. This intake starts with the complaint itself: the area, when it began, how it behaves, what the patient has tried already and whether it refers anywhere. It then asks about previous manual treatment and how the patient responded, which is directly relevant to how a first session is approached. A general health section covers current medication, recent accidents or falls, previous surgery to the area, pregnancy where applicable, and whether the patient has been advised to avoid particular movements, because those answers change what is appropriate rather than merely adding colour. The final section records consent to examination and adjustment as discussed, and gives the patient a place to raise anything they are anxious about, which experienced practitioners will say is one of the most useful lines on the form. As with every intake in this catalogue, it collects the patient's report and leaves interpretation to the examination.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
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
19 questions in total.
Example of a completed chiropractic intake form
A sample intake showing how a new patient describes their complaint before a first examination.
- Full name
- Tomas Nowak
- Date of birth
- 14/02/1985
- Main area of complaint
- Lower back, right side
- When did it begin?
- 3 weeks ago
- How does it behave?
- Worse with movement
- Does it spread anywhere else?
- Yes
- Have you had chiropractic or manual treatment before?
- No
- Any accident, fall or collision in the last year?
- No
- Anything you are anxious about
- Worried the adjustment might make the pain worse
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Have you had chiropractic or manual treatment before?”
- Makes answers required
If “Have you had chiropractic or manual treatment before?” is Yes, “How did you respond to it?” becomes required before the form can be submitted.
Driven by “Any accident, fall or collision in the last year?”
- Makes answers required
If “Any accident, fall or collision in the last year?” is Yes, “What happened, and when?” becomes required before the form can be submitted.
Driven by “Have you been advised to avoid any movements?”
- Makes answers required
If “Have you been advised to avoid any movements?” is Yes, “What were you advised to avoid?” becomes required before the form can be submitted.
Set it up step by step
- 1
Send it before the first visit
An examination appointment loses value if the first twenty minutes are spent writing history that could have arrived by email.
- 2
Keep the anxiety question
Patients who say what worries them get a better first session, and practitioners consistently report it changes how they explain what they are doing.
- 3
Ask about previous response, not just previous care
Whether a patient improved, flared or felt nothing last time is the useful half of that history.
- 4
Record consent as its own step
Consent to adjustment should be a visible question with a signature, not a line inside a block of clinic terms.
Mistakes to avoid
- Collecting a spine diagram but no history of accidents or surgery to the same area.
- Wrapping consent into the appointment booking so the patient never reads it.
- Asking about medication and then never opening the answer before treating.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Read the intake before the examination, plan around anything the patient has been advised to avoid, and keep the signed consent with the record.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the chiropractic intake form, matched on the words people actually search for.
Physiotherapy Intake Form
clinicclinicalconsenthealthhistory
Pediatric Intake Form
clinicclinicalconsenthealthhistory
Quick Patient Registration
clinicclinicalconsenthealthhistory
Dermatology Patient Intake Form
clinicclinicalhealthhistoryintake
Eye Exam Intake Form
clinicclinicalgeneralhealthhistory
Consent to Treatment Form
clinicclinicalconsenthealthhistory
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
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.
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