Southlake Chiropractic
1959 W Southlake Blvd #140
Southlake, TX 76092-6773
(817) 488-8837

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.)


Complaint Information

If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint. The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.

What is the purpose of your visit?
What is the reason for this visit?
Date of scheduled appointment
When did this condition begin?
How long have you had this condition?
What caused this condition?
Where is the discomfort?

Select only one area of discomfort for your chief complaint. Add additional areas of discomfort as additional complaints by selecting Yes in response to Do you have an additional complaint? at the bottom of this section.





Upper Extremity

Lower Extremity

Does the discomfort radiate/travel?
Describe the quality of the discomfort. Choose all that apply.
Describe the onset of the discomfort. Choose only one.
Describe the intensity of the discomfort. Choose only one.
Rate the severity of your discomfort on a scale of 1-10 where 1 is the least severe and 10 is the most severe.
Least severe <----------------------------> Most severe
How often do you feel this discomfort? Choose only one.
How has this complaint changed since the onset?
What activity is most significantly affected by this discomfort?
What aggravates this condition? Choose all that apply.
What improves this condition? Choose all that apply.
What treatment have you received for this condition up to now?
Were any diagnostic tests performed to assess this condition (including X-rays, MRIs, etc.)?
Have you ever had any previous episodes of this condition?
In what ways does this condition affect your life and your ability to function? Choose all that apply.
Do you have an additional complaint?

Review of Systems



Head, Eyes, Ears, Nose and Throat






Dermatological and Bleeding

Past, Family and Social History

List your (or the patient's) past surgical history. Choose all that apply and indicate the year in which the surgeries were performed.
Describe any past illnesses or conditions the doctor should be aware of and the age at which the illness(es) reportedly occurred. Respond respectively to each illness listed. If personal health history is good, select "No past illnesses (including diabetes, cancer, hypertension and progressive neurological diseases)"

List any past history of accidents or trauma. Choose all that apply.
Are you presently taking any medication?
List your (or the patient's) family health history. Choose all that apply to blood relatives only.
What are your (or are the patient's) current work habits? Choose all that apply.

How would you describe your (or the patient's) personal social habits? Choose all that apply.

How would you describe your (or the patient's) present exercise habits? Choose all that apply.
How would you describe your (or the patient's) diet and nutritional status? Choose all that apply.

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.

Chiropractic Experience

Please select all that apply.


If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:


I certify that I'm the patient and/or legal guardian listed above. If the above stated patient is a minor I authorize the licensed chiropractor, and whomever he may designate as assistants to perform diagnostic test if needed, and administer treatment to the above stated patient. 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 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 authorize and direct you, my insurance company, and/or attorney to pay directly to Devos Chiropractic PA, DBA Southlake Chiropractic and I give him permission to endorse his name to checks issued payable to myself and/or Dr. Devos or Southlake Chiropractic as consideration for his provision of those healthcare services which I received. 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. All co pays, co insurance, deductibles or customary fees are due when services are rendered. Consent to Chiropractic Services - Explanation of Risks Manipulation is considered one of the safest methods available for the treatment of many spinal and joint disorders. Every reasonable precaution is taken to reduce the risk of adverse effects for this and any treatment. However, as with any health care procedure, there are certain complications which may arise curing a manipulative adjustment. Those complications include but are not limited to: (1) Temporary aggravation of symptoms; (2) Other unlikely, but possible complications being stretch injuries to muscles, tendons and soft tissue, fracture or displacement of bones, disc injuries, injuries to nerves and occlusion of the blood vessels. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contribution to serious complications including stroke. Please note the exact incidence of serious complication is described as rare or very rare. I hereby consent to the performance of chiropractic procedures and diagnostics that the doctor of chiropractic may consider necessary or advisable in the course of my health care. I have read and understand the explanation of risks, and I acknowledge that no guarantees have been made to me concerning the result of treatment. I have read/understand the above statements as well as the included information above and certify it to be true and accurate to the best of my knowledge.

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


Finalizing Form

  1. Submit Form!