Core Chiropractic Health Center
1850 N. Milwaukee Ave.
Chicago, IL 60647

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

Employment Information

Current Symptoms

If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History

Family/Primary Physician

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Personal Incident History:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


For Women Only


Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Were You Aware That...

Health Problems & Concerns:

Please select all that you have had or currently have.

Worker's Compensation

Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?

Auto Accident

Visited a Hospital or Doctor?

Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Electronic Health Record (EHR) Information

Preferred Language: Ethnicity:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered


I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I understand the doctor may use spinal manipulative therapy (also called "chiropractic adjustment") in my treatment. This treatment consists of the doctor placing her hands or a mechanical instrument upon my body to move my joints. This may cause an audible "pop" or "click" sound. You may feel a sense of movement. As with any healthcare procedure, certain complications may arise during the chiropractic manipulation. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The doctor will make every reasonable effort during the examination to screen for contraindications to care; however, if I have a condition that would otherwise not come to her attention, it is my responsibility to inform the doctor. Fractures are rare occurrences and generally result from some underlying weakness of the bone which the doctor will check for during the history and exam. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare. In 2008, one study reported the risk to be 1 case per 400,000 cervical spine adjustments. This is the largest controlled research study to date on this issue. The other complications are also generally described as rare. Risks of remaining untreated: Delay of treatment may allow formation of adhesions, scar tissue, and other degenerative changes. These changes can further reduce skeletal mobility and induce chronic pain cycles. Risk of Covid-19: The World Health Organization has declared Covid-19 to be a pandemic. This office follows all CDC recommended steps for infection control, including appropriate staff and patient screening; all cleaning/ disinfecting protocols; and social distancing requirements. However, even strict adherence to these procedures cannot guarantee the complete absence of Covid-19 in any location, nor can it guarantee that Covid-19 transmission will never occur. By signing this form, I acknowledge the office's infection control procedures and understand that this office cannot completely eliminate the risk of exposure to Covid-19 on the premises. For parents or guardians signing on behalf of patients under 18 years old, This office observes all laws regarding a minor patient's right to consent, and to confidentiality of, his or her health care treatment. In addition, this office follows a policy of transitioning adolescent patients to self-management of their own. The office views patient visits as an opportunity for my child to learn to take responsibility for their health care. Therefore, as appropriate by age and maturity of the patient, parents may be asked to excuse themselves for a portion or the entire health care visit. By signing, I as the responsible party acknowledge understanding of and consent to this policy. By signing, I agree I have read and understand the explanation of the chiropractic adjustment as outlined. I state that I have weighed the risks and benefits involved in treatment and decided that it is in my best interest to undergo the treatment recommended. I understand the doctor will use her best professional judgment but cannot and does not guarantee any outcome or results. Having been informed of the risks, I hereby give my consent to treatment as outlined. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


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