FREE 9+ Chiropractic Intake Forms in PDF | MS Word

Even in the ever-changing technological advantages that the world evidently obtains from scientific and medical studies, some people seem to rely on alternative medicine rather than the conventional one that doctors prefer. One of the common alternative medicine options known to the population is called chiropractic therapy. This type of therapy focuses on healing the musculoskeletal and nervous system of a patient. The therapy clinics or practitioners who offer chiropractic treatment require their patients and clients to fill out chiropractic intake forms before their sessions are scheduled and will take place. You may also see client intake forms.

• Medical Intake Forms
• Medicine Patient Intake Forms

Chiropractic Intake Form Sample

What Is a Chiropractic Intake Form?

A chiropractic intake form is a document that chiropractic therapists and clinic assistants use for gathering important information of their clients. The form requires the client to disclose his general information such as his full legal name, contact numbers, residential addresses, occupation, and even the client’s date of birth. The client can also disclose his credit card details and his health insurance information to allow the therapy clinic staff in determining how much the client must pay for the treatment after the deduction from his insurance benefits and from the remaining credit allowance in his card.

Chiropractic Client Intake Form

Other details to be included in a chiropractic intake form includes the client’s health history and the details of which part of the client’s body is in current pain. Some intake forms for this type of therapy also has an area where the client is presented with a set of questions that determines the appropriate treatment to heal the client as well as distinguish the source of the client’s medical concerns.

Chiropractic New Patient Intake Form in DOC

Varieties of Chiropractic Intake Forms

Since there are numerous types of chiropractic therapies that highly depends on the method used for the client, there must also be different intake forms to address the varying concerns of a chiropractic therapy client. You may also see patient intake forms.

Below are some of the most common varieties of this form that chiropractic clinics can prepare and use:

1. Canine Chiropractic Intake Form – This chiropractic intake form is intended to be filled out by owners of animals in need of chiropractic care methods and therapies. Basically, the form contains the information of the pet or animal on the first section which is followed by the details of the owner or animal trainer. The form must also have the identification of the animal’s veterinarian in order to acquire the animal’s medical information from the vet’s records and data. To further identify the case of the animal, the owner must state what the activities and type of discipline methods are done by the animal along with the medical reports and list of medications that the animal is prescribed to take in.

Animals and pets are treated similarly to minor patients of therapy clinics wherein the owner or the trainer of the animal will have to sign a consent form attached to the intake document. It is significant that the owner has read the statements and points of the consent to assure that the animal will only be provided with the right care methods or procedures to address the medical concerns. Additionally, the animal’s veterinarian must also affix his signature on the consent form to indicate that he hereby grants consent to the clinic in providing care and medications to the animal as part of the therapy sessions.

Canine Chiropractic Intake Form

2. Chiropractic Acupuncture Intake Form – Although acupuncture is another type of alternative medicine procedure, some alternative medicine practitioners offer acupuncture along with chiropractic treatments for patients who are in need of comfort and relief for back or neuromuscular pains. You may also see coaching intake forms.

The combination of these therapies and treatments promote a faster phase of healing the patient and boost the patient’s health advantages. With this, therapists and clinics who offer the treatment combination must provide chiropractic acupuncture intake forms to their clients and patients. This form must cater the personal information of the client along with his complaint details, prior acupuncture information, medication list, medical history, pain and insurance information, and a disclosure with an informed consent statement to inform the client about the possibilities and limitations of the therapy.

Chiropractic Acupuncture Intake Form

3. Chiropractic Pediatric Intake Form – Pediatric patients are those who belong in the minority age, which is mostly the age of twenty and under. With this, the parents of a pediatric patient must be able to supervise their child when filling out any form or document and assure accuracy of the information given. Specifically, if a pediatric patient needs to undergo chiropractic therapy sessions, then the parents or his legal guardian will be provided with a chiropractic pediatric intake form.

This document contains a child information section to obtain the basic data of the patient, the reasons of why the patient needs the treatment and therapy, a questionnaire to be answered by the patient’s parents, as well as the prenatal history of the patient’s mother. Other details to be disclosed in this form includes the child’s or the patient’s stress test results and a medical agreement that must be signed by the parents to assign responsibilities and grant a permission for using the child’s medical information.

Chiropractic Pediatric Intake Form

4. Chiropractic Wellness Workers Compensation Intake Form – This chiropractic intake form is used only for gathering the details of a company worker or employee. The form is provided by the therapy clinic for patients who were involved in a workplace incident leading to the pain and medical concerns of the worker. Three sections are found in this form which is mainly for the details of the patient or the worker, the accident information, and the patient’s post-injury details. The patient information section must have the name of the injured worker along with his gender, employment information, marital status, and the identifications of his primary care provider and attorneys.

The second section of the form focuses on detailing the incident where the employee obtained his injury. This contains the date and time of the accident, the names of the witnesses, as well as a brief description of the accident. The last section must have the details of what happened after the accident and injury were acquired by the employee such as where he was sent for operation and the name of the physician who attended his medical needs. To complete the entries, the patient must affix his signature and the date of when he used the document at the bottom of the form. You may also see psychotherapy intake forms.

Chiropractic Wellness Workers Compensation Intake Form

5. Family Chiropractic Intake Form – This form is ideal for chiropractic therapy clinics who offer services and therapy sessions to patients of various ages ranging from toddlers to the elderly. The form has a family history section that is significant for distinguishing if a patient acquired his medical issues from his genes or from his bloodline. Since the form is to be used by anyone, a consent statement is indicated, which is addressed to all types of patients and whether the patient will allow his details and information to be disclosed to his healthcare provider and to third-party billing organizations or not. Different rules and regulations of the state or country related to the protecting the patient’s data are also found in this form to inform the patient about his rights for inspection and amendment to his own health information.

Family Chiropractic Intake Form

6. Pregnancy Chiropractic Intake Form – When it comes to attending the needs of pregnant women, medical practitioners and doctors must carefully take into account the various complications and risks that the patient can obtain during the treatment process, as a pregnant woman’s system is sensitive as well as the baby in the womb. With this, a pregnancy or prenatal chiropractic intake form must be completed by the pregnant patient. The form will highlight the primary complaints of the patient along with a few questions allotted to determine the main cause of the complaints. Additionally, a pregnancy chiropractic intake form can also contain a set of checkboxes where the patient must indicate a remark on the symptoms that she experienced and her reasons for why she needs immediate relief or therapy.

Pregnancy Chiropractic Intake Form

How to Create a Simple Chiropractic Intake Form

Although there are different chiropractic varieties, some practitioners and therapy clinics prefer to create their own documents that can be easily associated with their websites, database systems, and documentation procedures. If your clinic aims to have their own chiropractic intake form, then you must follow the steps below to create a simple yet effective document that caters the necessary information of any patient:

1. Add the name of the chiropractic clinic on the top of the form. This serves as an indication that the document is made and owned by your clinic. The clinic’s location can also be stated below the name along with the title of the form which is “Chiropractic Intake Form.” You may also see therapy intake forms.

2. Indicate a patient information area. The fields in this area must focus on the patient’s basic details such as his first and last names, address and contact numbers, and the patient’s employment and marital status. You may also see event planning intake forms.

3. Have an area allotted for the patient’s emergency contact details. Lines that allow the patient to state the full legal names of his emergency contact representatives or authorized persons along with their phone numbers must be allotted in this area. To assure that the chosen individuals are currently associated with the patient, an area must be included to distinguish the patient’s relationship to the named contact whether it is his parent or his physician.

4. Allocate a section for the patient’s medical details. To make this section, checkboxes can be considered to provide options for the patient to indicate his medical state. This section must be able to determine the patient’s medical condition, the types of surgeries previously acquired, the specific matters that can trigger the patient’s allergic reactions, as well as the medications that the patient took which includes vitamin and food supplements. In addition to this, a body diagram can also be attached as part of the form to allow the patient in marking areas where the pain is evident. Associated with the diagram are numbers that symbolize the level of pain that the patient feels identical to making a rating on a survey form.

5. Enlist social activities with checkboxes. In this section or area, the patient must be able to disclose what types of activities he is currently involved socially such as being part of groups or organizations and regularly taking alcohol or drugs. The number of hours that the patient is able to sleep per night should also be catered in this section along with stress level that the patient is dealing with in his everyday living. You may also see new patient intake forms.

6. Include a section for the patient’s payment details. This must have areas where the patient will be able to provide a credit card authorization if he will be paying through his cards or bank account. The patient’s insurance policy and benefits where the clinic can obtain the payment and determine discounts for the patient should also be disclosed as well as the name of the patient’s employer.

7. Incorporate agreements and policy statements. This is the last section of the form wherein the patient will be informed about the clinic’s house rules and his obligations in paying the price of the therapy sessions. Some of the agreements to be incorporated on the intake form includes a consent to treat statement, confidentiality agreement, medical information disclosure, and a policy agreement. With this, a signature block must be allotted for the patient’s signature to indicate that the patient agreed on the statements and that his disclosed data are factual.

Prenatal Chiropractic Intake Form

The Importance of a Chiropractic Intake Form

Chiropractic intake forms are essential documents that can aid any practitioner and therapist in knowing a chiropractic patient well enough before prescribing any medication and suggesting any healing method for the patient’s concerns. The form also promotes a better way of communicating between the patient and the therapist which will then follow a more effective healing process and a stronger patient-therapist relationship. Lastly, the form helps the clinic staff to have records of their patients and determine the statistical data for the number of patients they were able to cure or help within a specific period or year. You may also see family intake forms.