The Chiropractic Intake Form Template – Canada is offered in multiple formats including PDF, Word, and Google Docs. These options are both customizable and print-friendly, ensuring that they fit your requirements perfectly.
Chiropractic Intake Form Template – Canada Editable – PrintableSample
1. Patient Information 2. Emergency Contact 3. Medical History 4. Current Medications 5. Reason for Visit 6. Insurance Information 7. Consent for Treatment 8. Signature and Date
PDF
WORD
Examples
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Emergency Contact Name]
[Emergency Contact Relationship]
[Emergency Contact Phone]
[Insurance Provider]
[Policy Number]
[Group Number]
Please list any past surgeries, chronic conditions, or current medications: [Details]
Please describe your current symptoms or health concerns: [Details]
How often do you exercise? [Options: Sedentary, Light, Moderate, High]
What are your goals for chiropractic care? [Details]
I hereby consent to the treatment proposed by the chiropractor and agree to provide accurate information.
[Patient’s Signature]
[Date]
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
Do any family members have chronic conditions? [Yes/No. If yes, please specify:]
Please list any symptoms you are experiencing: [Details]
Have you received chiropractic, physical therapy, or other treatments previously? [Details]
What limitations do you have in daily activities? [Details]
How would you like to be contacted? [Options: Phone, Email, SMS]
Describe what you hope to achieve through chiropractic care: [Details]
I understand that I have the right to refuse treatment and consent to the care being provided.
[Patient’s Signature]
[Date]
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