Intake Form

1. Primary Patient Information

I am filling this form out for someone else

By checking the box above, you are indicating that the information provided in this form is for someone else (e.g. a child or spouse). To do so, you must enter your own name and e-mail address below, so that we may track who is actually submitting the form, and send e-mail notifications as needed. Note that in this case, a patient e-mail address is not required, so it does not need to be provided if the patient does not have their own.

Your First Name *

Your Last Name *

Your E-mail Address *

First Name *

Middle Name

Last Name *

E-mail Address *

Gender *

Address

City

State

Postal Code

Primary Phone

Cell Phone

Employer Name

Occupation

Preferred Method of Contact

Cell Provider

Age

Date of Birth

Marital Status

Spouse Name

Referred By

Number of Children

Children Names, Ages & Gender

2. Healthcare Concerns

Concern #1

Severity

Began

Had Before (When)

Began with Injury

Symptoms

Concern #2

Severity

Began

Had Before (When)

Began with Injury

Symptoms

Concern #3

Severity

Began

Had Before (When)

Began with Injury

Symptoms

Concern #4

Severity

Began

Had Before (When)

Began with Injury

Symptoms

Concern #5

Severity

Began

Had Before (When)

Began with Injury

Symptoms

Seen other doctors for these conditions?

Chiropractor

Medical Doctor

Other

Who and When?

3. Medical History

List all Surgical Operations & Years

LIST ALL Over the Counter & Prescription Medications you are on

When was your last auto accident

Have you had previous chiropractic care?

If you have, Dr. and Date

Have you ever been knocked unconscious?

Have you ever fractured a bone

If knocked unconscious or fractured a bone please describe.

Other Trauma

4. Insurance Information

Primary Insurance Carrier

Name of Insured

Insured Date of Birth

Insured Member ID

Secondary Insurance Carrier

Secondary Name of Insured

Secondary Insured Date of Birth

Secondary Insured Members ID

Contact in Case of Emergency

Emergency Contact Phone Number

Social Security Number

Create a password

Please use the field below to create a password for your patient record. This will allow you to save your progress and retrieve your information at later time if you cannot complete this form in one sitting. (Passwords must be at least 4 characters long.)

Password *

Confirm Password *

Verification *

Important: You must check the box above to continue. Important: You must complete the verification above to continue.

* indicates a required field

Intake Form

1. Primary Patient Information

2. Healthcare Concerns

3. Medical History

4. Insurance Information

5. Family Health History

Create a password

DD Palmer - The Father of Chiropractic

Contact Info