Get the free Patient Intake Form

This document collects comprehensive patient information required prior to chiropractic treatment, including personal details, medical history, symptoms, and consent for treatment and release of records.

How to fill out patient intake form

How to fill out patient intake form

1. Gather patient information: Collect basic details such as name, date of birth, address, and contact information.
2. Medical history: Ask about past medical conditions, surgeries, allergies, and medications currently being taken.
3. Family history: Inquire about family medical history that may be relevant to the patient's health.
4. Reason for visit: Have the patient describe their current health concerns or reasons for seeking medical attention.
5. Insurance information: Request details about the patient's insurance provider and policy number if applicable.
6. Emergency contact: Ask for the name and contact information of someone to reach in case of an emergency.
7. Review and submit: Go through the completed form with the patient to confirm accuracy and submit it to the healthcare provider.

Who needs patient intake form?

1. Patients visiting healthcare facilities for the first time.
2. Anyone seeking treatment or consultation with a medical professional.
3. Individuals requiring documentation for insurance purposes.
4. Patients undergoing routine check-ups or specialized treatment.

For pdfFiller’s FAQs

How do I make edits in patient intake form without leaving Chrome?

Download and install the pdfFiller Google Chrome Extension to your browser to edit, fill out, and eSign your patient intake form, which you can open in the editor with a single click from a Google search page. Fillable documents may be executed from any internet-connected device without leaving Chrome.

Can I create an electronic signature for signing my patient intake form in Gmail?

You can easily create your eSignature with pdfFiller and then eSign your patient intake form directly from your inbox with the help of pdfFiller’s add-on for Gmail. Please note that you must register for an account in order to save your signatures and signed documents.

How do I complete patient intake form on an Android device?

Use the pdfFiller mobile app and complete your patient intake form and other documents on your Android device. The app provides you with all essential document management features, such as editing content, eSigning, annotating, sharing files, etc. You will have access to your documents at any time, as long as there is an internet connection.

What is patient intake form?

A patient intake form is a document used by healthcare providers to collect essential information from patients before their appointments. It typically includes personal details, medical history, and other relevant data.

Who is required to file patient intake form?

All new patients and sometimes returning patients who have had significant changes in their health or personal information are typically required to fill out a patient intake form.

How to fill out patient intake form?

To fill out a patient intake form, a patient should read each section carefully, provide accurate information such as personal identification, contact details, medical history, and any medications currently being taken. It’s important to complete all sections as thoroughly as possible.

What is the purpose of patient intake form?

The purpose of a patient intake form is to gather comprehensive information to help healthcare providers understand a patient's medical background, needs, and any specific conditions that may influence their treatment.

What information must be reported on patient intake form?

Required information on a patient intake form generally includes the patient’s name, contact information, date of birth, insurance details, medical history, allergies, current medications, and emergency contact information.