Creative Wellness Chiropractic
Health History Intake

Health History Intake

Health History Intake

Intake to gather information about the health history of the patient to help create a specific treatment plan.

Name(Required)
Address(Required)

Insurance Information (Skip if not using insurance)

Are you the primary policy holder?
MM slash DD slash YYYY
Have you received chiropractic treatment in the past?(Required)

Patient Condition

Is your complaint:(Required)
If so what type (Ex: X-Ray, MRI, CT Scan etc)
MM slash DD slash YYYY
MM slash DD slash YYYY
Ex: Ice, heat, stretching, resting, massage etc.
Ex: Bending, lifting, exercise, resting etc.
How often do your symptoms occur?(Required)
Are your symptoms getting(Required)
What type of pain are you experiencing?(Required)
What lifestyle activities does this interfere with?(Required)
012345678910
012345678910

Patient Health History

Please check all of the following that apply(Required)

Personal Health History

Please check all of the following that apply(Required)
List Medications & Dosages:(Required)

Family History

Select all that apply:(Required)
Acknowledge and Agreement(Required)
MM slash DD slash YYYY
Print & Sign(Required)