QuestionPunkQuestionPunk
무료로 시작하기
모든 템플릿
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.

이 템플릿 사용하기템플릿 더 둘러보기

샘플 질문

템플릿에 포함된 내용을 미리 확인해 보세요. 모든 질문은 설문 공개 전에 자유롭게 수정할 수 있습니다.

질문 14개 · 약 7분
Q01
메시지

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
객관식필수

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
장문형

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

Q04
객관식필수

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
의견 척도필수

How would you rate your pain or discomfort right now?

척도: 0 – 10
최소:No pain최대:Worst pain imaginable
Q06
매트릭스

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

5개 행 × 5개 열
  • Sleep
  • Work or daily tasks
  • Exercise or physical activity
  • Mood or stress levels
  • Sitting or standing for long periods
열: Not at all · Slightly · Moderately · Significantly · Severely
Q07
객관식

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
객관식필수

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
단문형

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

Q10
객관식필수

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 인터뷰

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
동의

Informed consent to chiropractic evaluation and care

Q13
객관식

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
메시지

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.

포함된 기능

  • AI 후속 질문

    정형화된 설문이 놓치는 세부 내용을, 주관식 답변에 맞춰 AI가 심층 질문으로 끌어냅니다.

  • 주의력 확인 장치

    성의 없는 답변과 저품질 응답자를 걸러내는 내장 안전장치입니다.

  • AI가 작성한 문안

    문구, 질문 순서, 분기 로직까지 AI가 연구 목표에 맞춰 작성합니다.

  • 자동 리포트

    응답이 모이면 주요 주제, 인용문, 이해하기 쉬운 요약이 자동으로 작성됩니다.

다른 서비스와 비교

다른 설문 도구의 가장 유사한 템플릿을 검토했습니다. 그 도구들이 잘하는 점과, 이 템플릿이 한발 더 나아가는 지점을 정리했습니다.

이 템플릿을 선택하는 이유

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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.

잘하는 점

  • 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

아쉬운 점

  • 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

설문을 공개할 준비가 되셨나요?

이 템플릿을 편집기에서 열어 보세요. 첫 응답자가 보기 전에 모든 부분을 원하는 대로 바꿀 수 있습니다.

Use this template무료로 시작하기

관련 템플릿

같은 카테고리의 다른 설문을 만나 보세요.

전체 보기
Industry-Specific

Post-Interview Candidate Evaluation Survey

Captures structured feedback from interviewers right after a candidate interview — competency ratings, hiring recommendation, and top strengths — plus an AI follow-up that pulls concrete evidence and specific moments behind the recommendation instead of just a gut-feel score. Built for hiring managers and recruiting teams standardizing interviewer feedback across panels.

템플릿 보기
Industry-Specific

Tenant Satisfaction & Renewal Intent Survey

Measures how residents experience day-to-day property management — maintenance responsiveness, communication, common-area upkeep, and value for rent — plus renewal likelihood. An AI follow-up interview digs into the real story behind their most recent maintenance request or renewal decision, surfacing specifics that closed-ended ratings miss.

템플릿 보기
Industry-Specific

Pre-Market Listing Strategy Effectiveness Survey

Captures how sellers experienced the pre-market or 'coming soon' phase before their home went live on the open MLS — buyer interest, pricing signals, and agent support — with an AI follow-up that reconstructs why offers did or didn't materialize during that window. Built for real estate agents and brokerages deciding whether to keep offering a pre-market strategy.

템플릿 보기
Industry-Specific

프로그램 및 세션 참가자 피드백 설문

참가자가 워크숍, 교육 또는 프로그램을 어떻게 경험했는지 — 만족도, 특정 세션의 인지된 가치, 재참여 가능성 — 를 파악하고, 평가의 이유를 깊이 있게 탐구하는 AI 후속 질문과 결합하여 주최자가 다음번에 무엇을 유지하고, 고치고, 또는 없애야 할지 정확히 알 수 있도록 합니다.

템플릿 보기
Industry-Specific

Softball Tryout Player Evaluation Scorecard

A structured scorecard for coaches and scouts to rate a player's hitting, fielding, throwing, speed, and coachability right after a tryout, plus a roster recommendation. An AI follow-up interview digs into the specific plays or moments behind that recommendation so the reasoning isn't lost once the tryout ends.

템플릿 보기
Industry-Specific

Car Buying Decision Journey & Satisfaction Survey

Maps the full vehicle-purchase journey — research channel, decision factors, financing experience, and post-purchase satisfaction — for dealerships, manufacturers, and auto marketplaces. An AI follow-up interview reconstructs the actual negotiation and channel story behind the numbers, not just the checkbox answer.

템플릿 보기