QuestionPunkQuestionPunk
Start free
All templates

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.

Use this templateBrowse more templates

Sample questions

A preview of what’s in the template. Every question is editable before you launch.

14 questions · ~7 min
Q01
Message

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

Q02
Multiple ChoiceRequired

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
Long Text

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

Q04
Multiple ChoiceRequired

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
Opinion ScaleRequired

How would you rate your pain or discomfort right now?

Scale: 0 – 10
Min:No painMax:Worst pain imaginable
Q06
Matrix

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

5 rows × 5 columns
  • Sleep
  • Work or daily tasks
  • Exercise or physical activity
  • Mood or stress levels
  • Sitting or standing for long periods
Columns: Not at all · Slightly · Moderately · Significantly · Severely
Q07
Multiple Choice

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
Multiple ChoiceRequired

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
Short Text

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

Q10
Multiple ChoiceRequired

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 Interview

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
Consent

Informed consent to chiropractic evaluation and care

Q13
Multiple Choice

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
Message

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.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • 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.

What it does well

  • 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

Where it falls short

  • 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.

What it does well

  • 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

Where it falls short

  • 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

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

Use this templateStart free