Chiro intake

Health History

Complete each section as accurately as possible. Required fields are validated before the form is emailed to the clinic.

Fields marked * are required. Please answer the other questions that apply to you.

Patient and Current Care

Start with the details the clinic needs to identify the patient and understand immediate treatment priorities.

Patient name *

Prioritize the areas of your body that you would prefer to receive treatment *

Have you taken anti-inflammatory medication, pain killers, muscle relaxants, or mood-altering medication within the past two hours? *

YesNo

If yes, what and how much?

List exercises or recreational activities you do regularly, including frequency

Do you eat well?

YesNo

Do you take supplements?

YesNo

If yes, which supplements?

Are you currently seeing a medical practitioner?

YesNo

If yes, please explain

Date of last MD check-up

Previous History

Include year and type where applicable.

Surgeries

Accidents

Special notes: pins, wires, artificial joints, limbs, etc.

Hospitalizations

Current Medications and Lifestyle

Add medication names, conditions treated, and tobacco or substance details.

Conditions

Please indicate any of the following conditions that apply to you, past or present.

Pain Map

Mark areas of pain or sensation using pins. This replaces the paper body diagram.

Choose a marker type

Body diagram with hands, feet, head, front body, and back body

Tap the diagram to add pins. Drag a pin to adjust it. Coordinates are saved proportionally so they stay aligned on mobile and desktop.

Pain scale: 0 / 10

No painExtreme pain

Condition Story

These answers help the clinician understand what started the concern and how it affects daily life.

What are your goals for receiving chiropractic care?

How did this condition develop? What caused it, and how did it start?

What makes this condition worse?

What makes it better?

When was the first time you were aware of this condition?

Have you ever had this problem before?

YesNo

If yes, when?

How often does this problem affect you?

How long does it last?

Does the pain radiate from the source of pain?

YesNo

If yes, where?

Have you ever received treatment for this condition?

YesNo

Who, when, where, what treatment, and what results?

Has this condition been getting...

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Daily Life and Family History

Add work, activity, sleep, family history, imaging, and stress information.

Before submitting

Please review your answers. This form will be emailed to Madison Clinic and is not stored by this website.

Health History

Patient and Current Care

Previous History

Current Medications and Lifestyle

Conditions

Specific Muscle / Joint Pain

Head / Neck

Skin

Infectious Conditions

Respiratory System

Muscles / Joints

Female

Nervous System

Digestive System

Heart / Circulation

Other

Other Healthcare Received

Pain Map

Condition Story

Daily Life and Family History

Before submitting