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Chiropractic New Patient Intake Form Template

A printable new patient form for chiropractic clinics that covers the presenting complaint, history and red flags, and informed consent to chiropractic examination and treatment.

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Last reviewed September 2026 · Not legal advice

Ask about red flags before the first adjustment

The intake should surface the reasons not to adjust, or to refer: recent trauma, neurological symptoms, unexplained weight loss, and history of cancer or osteoporosis. Asking on paper means it is asked every time.

Informed consent should describe what chiropractic care involves and its risks in plain language, and record that the patient can ask questions and decline any part of the treatment.

Clinic name · address · phone

Chiropractic New Patient Intake Form

Client

Full name

Date of birth

Phone

Complaint

Main complaint and when it started

Pain now (0–10)

Previous treatment for this problem

Health history

Recent accident or trauma? Yes NoIf yes, details

Numbness, tingling, or weakness? Yes NoIf yes, details

History of cancer, osteoporosis, or stroke? Yes NoIf yes, details

Unexplained weight loss or night pain? Yes NoIf yes, details

Pregnant? Yes No

Medications

Informed consent

InitialsI understand chiropractic care may include spinal manipulation, soft tissue therapy, and exercise advice.

InitialsI understand common effects include soreness or stiffness, and that rare serious risks exist, which have been explained to me.

InitialsI understand I may ask questions or decline any treatment at any time.

InitialsI have answered health questions accurately.

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/chiropractic-new-patient-intake-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for chiropractic clinics.

Frequently asked questions

Should consent be repeated?

Many clinics reconfirm consent at each new region or plan of care. Check your college's standard.

Where do I record the examination?

In the initial assessment, not the intake.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.