Creative Wellness Chiropractic
Health History Intake

Health History Intake

Health History Intake Form

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)

Why a Health History Intake Form Is Important

Completing a health history intake form is a critical first step in receiving safe and effective chiropractic care. Your answers help us understand your medical background, current symptoms, lifestyle factors, and health goals so we can create a personalized treatment plan.

At our San Diego chiropractic office, we use your intake information to ensure care is appropriate, targeted, and tailored specifically to you.

What Information Is Included in the Health History Intake Form

Our health history intake form for chiropractic care includes questions designed to give us a complete picture of your health. You may be asked about:

  • Current pain or symptoms
  • Past injuries or surgeries
  • Auto accidents or work-related injuries
  • Pregnancy status (if applicable)
  • Medications and supplements
  • Chronic conditions
  • Lifestyle factors such as activity level, sleep, and stress

This information allows your chiropractor to safely assess your condition and determine the most effective approach to care.

How Your Intake Form Helps Personalize Chiropractic Care

No two patients are the same. Completing a health history intake form at a chiropractic office allows us to customize care based on your unique needs.

Your intake helps us:

  • Identify contraindications or precautions
  • Determine which chiropractic techniques are most appropriate
  • Decide if additional therapies such as SoftWave TRT, massage therapy, or Normatec compression may be beneficial
  • Track progress and outcomes over time

Personalized care leads to better results and a safer treatment experience.

Secure & Confidential Patient Information

Your privacy matters. All information provided on your health history intake form is kept secure and confidential in accordance with healthcare privacy standards.

We use your information only for:

  • Clinical decision-making
  • Treatment planning
  • Insurance documentation (when applicable)

Your data is never shared without your consent.

When to Complete Your Health History Intake Form

We recommend completing your health history intake form for our San Diego chiropractic office before your first appointment whenever possible. This allows your chiropractor to review your information in advance and make the most of your visit.

If you’re unable to complete the form ahead of time, we’re happy to assist you in the office.

Health History Intake for Auto Accident & Insurance Cases

If you are seeking care for a car accident or personal injury, your intake form plays an especially important role. Detailed health history documentation helps support:

  • Accurate diagnosis
  • Treatment planning
  • Insurance and personal injury claims

Providing thorough and honest answers ensures your care and documentation are complete.

What Happens After You Submit Your Intake Form

Once your health history intake form is submitted, your chiropractor will review your information and discuss it with you during your appointment. This includes:

  • Clarifying symptoms or concerns
  • Performing a physical and chiropractic examination
  • Discussing recommended care options

Our goal is to make your experience comfortable, informed, and stress-free.

Start Your Chiropractic Care in San Diego

Completing your health history intake form is the first step toward better health. Our San Diego chiropractic office is committed to providing personalized, evidence-based care in a supportive environment.

Complete Health History Intake Form

Schedule Your Appointment Today!