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Chiropractic intake form with a pain-mapping canvas

New patients rarely describe pain well on paper: "lower back, kind of left?" A body outline they can draw on shows you the spot before they walk in.

Try it now

Name *

Circle or mark a spot on the outline *

Demo only — nothing here is sent.

Patient circles the area of pain on a front and back outline, then rates it on a 0–10 scale.

Add the usual intake fields around the drawing: history, medications, prior injuries, consent.

The drawing arrives in your inbox with the rest of the answers, ready before the first visit.

Yes. They draw with a finger on the outline; the form works on any phone browser with nothing to install.

Not unless you turn storage on for a form. By default a submission is emailed to you and not kept.