Classic form

Chiropractic intake form with a spine history grid

A chiropractor examining a lower back needs to know what the neck, the mid back and the jaw have been doing for the last three months, and asking that one region at a time takes the whole appointment. This seventeen field form puts eight regions in a single grid and screens for the conditions that change the plan.

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Top of the chiropractic intake form with a spine history grid example — The top of the form as it renders. The image was generated for this example.

The form itself

A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.

New patient form, Align Chiropractic

Please complete before your first visit. The grid in the middle takes two minutes and saves about ten at the start of the appointment.

About you

Your name *

Title

First

Last

Date of birth *

Phone *

Email *

Your work, and how your day is spent *

Your GP and their practice *

Why you are here

The answers below are clinical information. They are read by the chiropractor treating you, held in the practice records for the period required by law, and are not given to an employer, an insurer or anyone else without your written consent.

What is the main problem, in your own words? *

How long has it been going on? *

Under a week

1 to 4 weeks

1 to 6 months

6 to 24 months

More than 2 years

It comes and goes over years

How would you describe the pattern? *

Constant, it never fully settles

Worse in the morning, easier as the day goes on

Fine in the morning, worse by the evening

Only with certain movements

Only after sitting or standing for a long time

Unpredictable

The grid below covers the whole spine, not only the part that hurts today. Answer for the last three months. A region you have never had trouble with is a useful answer, so please do not leave a row blank.

Spine and related regions, over the last three months *

	Never	Occasionally	Weekly	Daily
Neck stiffness or pain
Headaches starting at the base of the skull
Between the shoulder blades
Lower back
Pain travelling down an arm
Pain travelling down a leg
Jaw clicking or pain
Rib or chest wall tightness

What has been done already

Have you been adjusted by a chiropractor before? *

Never

Yes, and it helped

Yes, and it did not help

Yes, and I had a bad reaction

Yes, years ago and I do not remember much about it

Have you had imaging of your spine? *

No imaging

X ray, in the last two years

X ray, more than two years ago

CT or MRI, in the last two years

CT or MRI, more than two years ago

I have had imaging but I am not sure what kind

Other treatment you have tried for this

Health screen

Do any of these apply, now or in the past? *

Osteoporosis or low bone density

Inflammatory arthritis, including rheumatoid or ankylosing spondylitis

A blood thinning medication or a bleeding disorder

Cancer, current or previous

A stroke, a transient ischaemic attack or a known artery condition

Spinal surgery, fusion or hardware

Recent significant trauma, including a fall or a collision

Pregnancy

Numbness in the saddle area, or a change in bladder or bowel control

None of these

Medications and supplements you take

What would a good outcome look like for you? *

Getting out of pain, nothing more

Getting out of pain and understanding why it happened

Returning to a specific activity

Managing something long term

A second opinion before I decide on surgery

Consent

Chiropractic care commonly involves manual adjustment of spinal joints, soft tissue work and exercise. Mild soreness or stiffness for a day or two afterwards is common. Serious complications are rare, and the screening questions above exist to identify the situations where a different approach or a referral is appropriate. You may ask questions, ask for a technique to be changed, or stop at any time, and you do not have to explain why. Signing records that this has been read and that you consent to examination and to care as it is explained to you.

Signature *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your nameNameRequired
Date of birthDateRequired
PhoneShort textRequired
EmailShort textRequired
Your work, and how your day is spentShort textRequired
Your GP and their practiceShort textRequired
What is the main problem, in your own words?Long textRequired
How long has it been going on?Single choiceRequired: Options: Under a week · 1 to 4 weeks · 1 to 6 months · 6 to 24 months · More than 2 years · It comes and goes over years
How would you describe the pattern?Single choiceRequired: Options: Constant, it never fully settles · Worse in the morning, easier as the day goes on · Fine in the morning, worse by the evening · Only with certain movements · Only after sitting or standing for a long time · Unpredictable
Spine and related regions, over the last three monthsRating gridRequired: Statements:
Neck stiffness or pain
Headaches starting at the base of the skull
Between the shoulder blades
Lower back
Pain travelling down an arm
Pain travelling down a leg
Jaw clicking or pain
Rib or chest wall tightness
Have you been adjusted by a chiropractor before?Single choiceRequired: Options: Never · Yes, and it helped · Yes, and it did not help · Yes, and I had a bad reaction · Yes, years ago and I do not remember much about it
Have you had imaging of your spine?Single choiceRequired: Options: No imaging · X ray, in the last two years · X ray, more than two years ago · CT or MRI, in the last two years · CT or MRI, more than two years ago · I have had imaging but I am not sure what kind
Other treatment you have tried for thisLong text
Do any of these apply, now or in the past?Multiple choiceRequired: Options: Osteoporosis or low bone density · Inflammatory arthritis, including rheumatoid or ankylosing spondylitis · A blood thinning medication or a bleeding disorder · Cancer, current or previous · A stroke, a transient ischaemic attack or a known artery condition · Spinal surgery, fusion or hardware · Recent significant trauma, including a fall or a collision · Pregnancy · Numbness in the saddle area, or a change in bladder or bowel control · None of these
Medications and supplements you takeLong text
What would a good outcome look like for you?Single choiceRequired: Options: Getting out of pain, nothing more · Getting out of pain and understanding why it happened · Returning to a specific activity · Managing something long term · A second opinion before I decide on surgery
SignatureSignatureRequired

What each block of this form collects

The first block is four identity fields, a question about what the working day does to the body, which for a spinal complaint is often the history that matters most, and the patient GP, which is who a referral letter goes to if the health screen turns something up. The complaint block asks the problem in the patient own words first, then two structured questions that a free text answer rarely covers: how long it has been going on, and the pattern, with options that separate morning stiffness from evening fatigue because those point in different directions. The grid is the centre of the form. What has been done already covers previous adjustments and imaging, both as radios with honest options. The health screen is ten lines and the last of the nine conditions is the one that changes everything.

Why a whole spine grid instead of a body map

A patient books an appointment about one region and thinks about one region, but a chiropractor assesses the chain. Asking eight separate questions about places that do not currently hurt feels repetitive and gets skipped; a single grid with never, occasionally, weekly and daily takes two minutes and gets every row answered, which is why the paragraph above it asks specifically that no row be left blank. The rows are chosen for what they change: headaches starting at the base of the skull, pain travelling down an arm or a leg, and rib or chest wall tightness are each the kind of finding that alters an examination plan, and the jaw row catches the clenching that quietly drives a proportion of neck complaints.

How to adapt this form

A practice focused on paediatric care replaces the work question with a birth and developmental history block and cuts the grid to four rows, because a six year old does not have a three month pattern to report. A sports chiropractic clinic adds a training load question and a return to competition date, and expands the imaging radio to include scans ordered by a club physiotherapist. A multidisciplinary clinic sharing one intake across chiropractic, physiotherapy and podiatry keeps the grid and the health screen exactly as they are and adds a first question asking which practitioner the appointment is with, which routes the remaining sections.

What makes this form work

Eight regions in one grid, rated over three months

Never, occasionally, weekly and daily across neck, headaches, mid back, lower back, arm, leg, jaw and ribs. The paragraph above asks that no row be left blank, so a region that has never given trouble is recorded as an answer rather than as a gap.

The pattern question separates morning from evening

Six options including worse in the morning and easier as the day goes on, and fine in the morning and worse by the evening. Those two point at different mechanisms, and neither reliably appears in a free text description of the pain.

The health screen ends with the urgent line

Nine conditions from osteoporosis to recent trauma, then numbness in the saddle area or a change in bladder or bowel control, then none of these. That second last option is the one that means a phone call rather than an appointment, and every patient is asked it.

Questions people ask

Why does a chiropractic form ask about the jaw and the ribs?

Because both change what an examination looks for. Jaw clicking and clenching commonly travel with neck pain and headaches, and rib or chest wall tightness can mimic or accompany mid back complaints. Neither is something a patient thinks to mention when they booked about a sore lower back, so the grid asks directly rather than waiting for it to come up.

What is a red flag screen and why is it on an intake form?

It is a list of conditions and symptoms that mean the usual approach needs changing or a referral is appropriate. Osteoporosis, blood thinners, inflammatory arthritis, previous stroke and recent trauma all sit on that list. The last line, saddle numbness or a change in bladder or bowel control, is the one that needs same day medical attention rather than an adjustment.

Why offer I had a bad reaction as an option for previous adjustments?

Because it is a real answer and it changes the first appointment completely. A patient who had a bad experience will often say nothing if the choices are only yes and no, and then tense through an examination. Naming the option gives them a way to raise it before they are on the table, which is exactly where that conversation belongs.

Does the form need imaging uploaded?

This version asks what imaging exists rather than collecting it, including an option for a patient who knows they had a scan but not what kind. That answer is enough for the chiropractor to request the report from the referring practice or the imaging provider, and it keeps the form short.

Should consent be a checkbox as well as a signature?

Here the paragraph and the signature do the work together. The paragraph names manual adjustment, the common soreness afterwards, the rarity of serious complications and the right to stop at any time without explaining why. The signature records that it was read.

How long should a chiropractic intake form take?

About ten minutes, which is what seventeen fields with one grid comes to. The value is in the trade: two minutes on the grid and one on the health screen returns roughly ten minutes of the first appointment, which is the difference between a rushed examination and a conversation about what the findings mean.

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Other form examples

Physiotherapy intake form built around one injury

A physiotherapist has about forty minutes and needs a third of it to examine, so the history has to arrive before the patient does. This eighteen field intake form maps the region and side, the onset, the pain score and what aggravates it, then records which funding pathway is paying.

Massage intake form that asks about pressure before the table

A client lying face down with their eyes closed will almost never ask for lighter pressure or say that they would rather their feet were left alone. This fourteen field intake form asks both in advance, alongside a contraindication screen that adapts the technique rather than cancelling the booking.

Psychology intake form with the limits of confidentiality on it

A first psychology session has fifty minutes and a person who has usually waited weeks for it, so the history should not eat the first twenty. This twenty field intake form takes the referral pathway, a ten item distress baseline and the supports already in place, and states the limits of confidentiality above the signature.

Want the steps in the builder? Read Every form field and when to use it, then Control who can fill in your form. For everything this generator can do, see the form maker.

Sources

Written and checked by the OneCraft team. Last checked 12 September 2026.