--- title: "Health History Intake" url: "https://yourchiropractorinsandiego.com/health-history-intake-form/" post_type: "page" date_published: "2023-05-26T23:49:50-07:00" date_modified: "2026-02-17T21:13:10-08:00" --- # 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) First Last Email(Required) Cell Phone Provider(Required) VerizonAT&TT-MobileCricket WirelessMint MobileBoost MobileMetro PCSOther Home Phone Cell Phone(Required) Work Phone Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Insurance Information (Skip if not using insurance) Primary Insurance(Required) Insurance ID #(Required) Group # Insured's Name(Required) Are you the primary policy holder? Yes No Insured's Date of Birth(Required) MM slash DD slash YYYY Have you received chiropractic treatment in the past?(Required) Yes No Patient Condition Primary Chief Complaint(Required) Is your complaint:(Required) Work Related Auto Accident Sport/Injury Slip/Fall Other Have you received any Imaging?(Required) If so what type (Ex: X-Ray, MRI, CT Scan etc) Date of Imaging(Required) MM slash DD slash YYYY When did you symptoms start?(Required) Less than an month ago1-3 months3-6 months6-12 monthsMore than a year Specific Date Symptoms Began: MM slash DD slash YYYY How did your symptoms start?(Required) What makes them better?(Required) Ex: Ice, heat, stretching, resting, massage etc. What makes them worse?(Required) Ex: Bending, lifting, exercise, resting etc. How often do your symptoms occur?(Required) Constant Frequent Intermittent Occasional Are your symptoms getting(Required) Worse Better Staying the same What type of pain are you experiencing?(Required) Sharp Achy/Dull Throbbing Stabbing Burning Shooting Numb What lifestyle activities does this interfere with?(Required) Sitting Lifting Bending Walking Traveling Exercising Standing Sleeping Social/Recreational Activites Personal Care (washing, dressing etc) Select All Select your pain level today (with 0 being no pain and 10 being the most pain)(Required) 0 1 2 3 4 5 6 7 8 9 10 Select your general pain level (with 0 being no pain and 10 being the most pain)(Required) 0 1 2 3 4 5 6 7 8 9 10 Please describe the onset of your complaints(Required) Patient Health History Please check all of the following that apply(Required) Neck pain Mid-back pain Low back pain Headaches Hip pain Shoulder/Elbow/Wrist pain Knee/Foot/Ankle pain Dizziness Tingling Numbness Fatigue Stress Visual problems Select All Personal Health History Please check all of the following that apply(Required) Alcohol/Drug Dependence Fever with stiff neck Diabetes High Blood Pressure Stroke Corticosteroid Use (Cortisone, Prednisone, etc) Taking Birth Control Pills Dizziness/Fainting Epilepsy/Seizures Numbness in the groin/buttocks Cancer/Tumor Osteoporosis Arthritis (Any type) Sinus Problems Difficulty Breathing Artificial Bones/Joint Replacements Prostate Problems Menstrual Irregularity Urinary Problems Abnormal Weight gain/loss Morning Pain/Stiffness Pain at Night Visual Disturbances Surgeries Tobacco Use (Current or Past) Select All Currently Pregnant? If so, how many weeks?(Required) Past slips/falls/traumas/accidents (list dates and explain)(Required) List Medications & Dosages:(Required) Add Remove Height(Required) Weight(Required) Family History Select all that apply:(Required) Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis Select All Acknowledge and Agreement(Required) I agree to the information stated above. We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. I certify to the best of my knowledge the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore, I give authorization to my chiropractor to contact my physician, if necessary. Today's Date(Required) MM slash DD slash YYYY Print & Sign(Required) Print Name E-Signature Δ 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. Completing your health history intake form allows our chiropractic team to better understand your overall health, past injuries, and current concerns before your visit. This information helps us create a personalized care plan that is safe, effective, and tailored to your specific needs. All health information submitted through our intake forms is kept confidential and used solely for the purpose of providing appropriate chiropractic and wellness care. If you have questions while completing your form, please contact our office and we will be happy to assist you prior to your appointment. Complete Health History Intake Form We follow best practices for patient privacy in accordance with guidelines outlined by the U.S. Department of Health & Human Services. Schedule Your Appointment Today!