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すべてのテンプレート
Industry-Specific

New Patient Chiropractic Intake & Pain History

A pre-visit intake for chiropractic practices that captures the presenting complaint, pain history, functional impact, and safety-relevant health background — plus an AI follow-up interview that reconstructs the mechanism of injury and treatment history in the patient's own words before they ever sit in the chair.

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設問の例

テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。

全14問・約7分
Q01
メッセージ

Welcome! Before your first visit, we'd like to understand what's bringing you in and how it's affecting you. Your responses are completely confidential and anonymized. This takes about 8 minutes and helps your chiropractor prepare for your appointment.

Q02
選択式必須

What is the main reason for your visit?

  • Back pain
  • Neck pain
  • Headaches
  • Joint pain (shoulder, hip, knee, etc.)
  • Injury recovery
  • Posture or mobility concerns
  • General wellness / maintenance care
  • Other
Q03
自由回答（長文）

In your own words, describe what's going on — where it hurts, what it feels like, and anything that seems to trigger it.

Q04
選択式必須

When did this issue first begin?

  • Within the last few days
  • Within the last month
  • 1–6 months ago
  • More than 6 months ago
  • This is a recurring or chronic issue
Q05
オピニオンスケール必須

How would you rate your pain or discomfort right now?

スケール: 0 – 10
最小:No pain最大:Worst pain imaginable
Q06
マトリクス

How much is this issue currently affecting each of the following?

5行 × 5列
  • Sleep
  • Work or daily tasks
  • Exercise or physical activity
  • Mood or stress levels
  • Sitting or standing for long periods
列: Not at all · Slightly · Moderately · Significantly · Severely
Q07
選択式

Which of the following have you already tried for this issue?

  • Chiropractic care
  • Physical therapy
  • Massage therapy
  • Over-the-counter or prescription medication
  • Injections or surgery
  • Rest / no treatment yet
Q08
選択式必須

Do any of the following apply to your current health? (This helps your chiropractor plan care safely.)

  • Previous spinal surgery
  • Osteoporosis or bone density concerns
  • Currently pregnant
  • Take blood thinners
  • History of numbness, tingling, or weakness in arms/legs
  • Recent unexplained weight loss or fever
Q09
自由回答（短文）

Please list any current medications or supplements you're taking (or write 'none').

Q10
選択式必須

What's your main goal for care with us?

  • Eliminate the pain
  • Improve mobility or flexibility
  • Prevent this from happening again
  • Return to sport or a physical activity
  • Ongoing wellness and maintenance
Q11
AIインタビュー

Reconstruct the story behind this patient's main complaint: what they were doing when it started (or how it developed if gradual), what makes it better or worse day to day, and how prior treatments (if any) actually went. If they mentioned numbness, tingling, weakness, or unexplained weight loss or fever, gently flag that this is worth discussing with the chiropractor directly rather than probing further.

Q12
同意

Informed consent to chiropractic evaluation and care

Q13
選択式

What is your age range? (Optional — helps us tailor care by life stage.)

  • Under 18
  • 18–29
  • 30–44
  • 45–59
  • 60–74
  • 75+
  • Prefer not to say
Q14
メッセージ

Thank you! Your responses will be shared with your chiropractor ahead of your appointment so your first visit can focus on getting you the right care.

含まれる機能

  • AIによる深掘り

    自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。

  • 注意確認設問

    急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。

  • AIが作成する設問文

    文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。

  • 自動レポート

    回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。

他ツールとの比較

ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。

このテンプレートを選ぶ理由

  • Goes beyond static intake fields with an AI follow-up interview that reconstructs the mechanism of injury and treatment history in the patient's own words before the first visit
  • Combines structured safety-relevant health background (medications, contraindication checklist) with an open-ended description field and a matrix rating functional impact across multiple life areas
  • Includes a proper informed consent step alongside pain scaling, onset timing, and prior-treatment history, giving chiropractors a fuller clinical picture than checkbox forms alone
  • Uses transparent, auditable prompts for the AI portion and generates an automated report so the chiropractor sees a synthesized story, not just raw answers

Jotform

Chiropractic Intake Form Template

This is a fielding-ready static intake form built on Jotform's drag-and-drop form builder, covering standard patient and health history fields. It's designed for quick deployment and customization but relies entirely on fixed fields rather than any adaptive questioning. Good for basic paperwork digitization, not for capturing nuanced pain narratives.

優れている点

  • Easy to customize with Jotform's widely-used drag-and-drop builder
  • Likely integrates with Jotform's broader form ecosystem (e-signature, payment, HIPAA add-ons)
  • Fast to deploy for practices already using Jotform

物足りない点

  • Static form fields only — no adaptive AI follow-up to probe deeper into a patient's specific complaint
  • No mechanism to reconstruct mechanism-of-injury narrative in the patient's own words beyond what's typed into a fixed field
  • No published methodology or scoring system for evaluating response quality or depth

Typeform

Chiropractic Intake Form Template

Typeform offers a conversational-style, fielding-ready intake template with its signature one-question-at-a-time flow, which improves completion experience over dense paper forms. It's still a fixed sequence of pre-set questions, however, with no ability to dynamically follow up based on a patient's specific answer. Useful for a friendlier front-end experience, not for deeper narrative reconstruction.

優れている点

  • Polished, conversational UI that likely improves patient completion rates versus traditional forms
  • Simple to brand and embed on a practice's website or booking flow
  • Mobile-friendly question-by-question format

物足りない点

  • No adaptive AI interview — every patient sees the same fixed question set regardless of their answers
  • No automated quality scoring of open-text responses or transparent prompt methodology
  • No built-in voice interview option or guided screen-share task capability

よくあるご質問

「New Patient Chiropractic Intake & Pain History」テンプレートにはどのような設問が含まれていますか？

すぐに使える設問が14問含まれており、最初の設問は次のとおりです：「Welcome! Before your first visit, we'd like to understand what's bringing you in and how it's affecting you. Your respon…」・「What is the main reason for your visit?」・「In your own words, describe what's going on — where it hurts, what it feels like, and anything that seems to trigger it.」。すべての設問は上でプレビューでき、自由に編集できます。

このアンケートの回答にはどのくらい時間がかかりますか？

回答者は通常、14問を約7分で回答し終えます。

テンプレートは編集できますか？

はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。

このテンプレートは無料で使えますか？

はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。

公開の準備はできましたか？

このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。

このテンプレートを使う無料で始める

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