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Chiropractic Initial Exam Template
A chiropractic initial exam records the new-patient history, red flag screen, examination, diagnosis, informed consent, and a plan of care with goals. Copy the free template, see two filled examples, and check what goes in each section.
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- Two filled examples
Blank chiropractic initial exam template
FreeCHIROPRACTIC INITIAL EXAM Patient: [Name] Date of birth: [Date] Date of exam: [Date] Referred by: [Self, physician, or other] Occupation and activities: [Job demands, sport, hobbies] Chiropractor: [Name, credentials] HISTORY Chief complaint: [Main problem and region, in the patient's words] Onset: [When it began, and the mechanism: injury, overuse, or no clear cause] Symptoms: [Quality, rating out of 10 now and at worst, radiation, numbness or tingling] Pattern: [What aggravates and eases it, and how it changes through the day] Previous episodes: [Past episodes, imaging, care received, and how it helped] Health history: [Conditions, surgeries, fractures, osteoporosis, blood thinners, current medications] Functional limits: [Work, sleep, exercise, daily tasks; baseline outcome measure score] Patient goals: [What the patient wants to be able to do again] RED FLAG SCREEN Serious conditions: [Cancer history, unexplained weight loss, fever, constant night pain, recent trauma, long-term steroid use] Nerve compromise: [Saddle numbness, bladder or bowel changes, progressive weakness, unsteady gait] Neck and head: [Dizziness, double vision, slurred speech, trouble swallowing, drop attacks, sudden severe headache] Outcome: [No red flags, or the finding and what was done] EXAMINATION Vital signs: [BP, pulse, height, weight] Observation: [Posture, gait, muscle wasting, swelling] Active range of motion: [Each direction in degrees or percent of normal, with pain] Palpation: [Tenderness, muscle tone, trigger points, by side and level] Motion palpation: [Fixated or hypomobile segments and joints] Orthopedic tests: [Name, side, and result of each test] Neurological exam: [Dermatomes, myotomes, reflexes, upper motor neuron signs] IMAGING Indication: [Imaging indicated or not, and the reason] Prior imaging: [Studies and reports reviewed, or none] DIAGNOSIS Working diagnosis: [Diagnosis by region, with the findings that support it] Differential: [Other causes considered, and why they are less likely] Prognosis: [Expected course, and factors that may slow recovery] INFORMED CONSENT Explained: [Proposed care, common and rare material risks, expected benefits, and alternatives, including no care] Agreement: [Questions answered, and verbal or written consent given] TREATMENT PLAN Today's treatment: [Adjustments by region and technique, other therapies] Frequency: [Visits per week and number of weeks] Short-term goals: [Measurable goals for the next 2 to 4 weeks] Long-term goals: [Functional goals for the end of the plan] Self-care: [Exercises, activity changes, workstation or sport advice] Re-exam: [Date or visit number of the first re-exam] Co-management: [Referrals or other clinicians involved, or none] Signed: [Chiropractor name, credentials, date and time]
Use it for
- New patient exams
- New injuries
- Return after discharge
- Setting a care plan
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Chiropractic initial exam: neck and shoulder pain
Chiropractic clinic, new patient
History
34-year-old woman, office worker, self-referred. Right-sided neck pain spreading to the top of the right shoulder and between the shoulder blades for 6 weeks, with no injury. Started after moving to a laptop at the kitchen table. Aching, 5/10 now and 7/10 by the end of the workday. No arm pain, numbness, or tingling. Eases with heat and walking. First episode; no imaging or previous care. Healthy; no regular medications. Wakes once a night when lying on her right side. Neck Disability Index 24%. Goal: get through a workday without neck pain, and return to yoga.
Red flag screen
No history of cancer, weight loss, fever, trauma, or steroid use. No numbness, weakness, or change in gait. No dizziness, double vision, trouble speaking or swallowing, drop attacks, or sudden severe headache. No red flags.
Examination
BP 116/74, pulse 68. Height 165 cm (65 in), weight 61 kg (134 lb). Forward head and rounded shoulders. Cervical flexion full; extension 45°, with pain at end range; rotation 60° right and 75° left; left lateral flexion pulls on the right. Tender, hypertonic right upper trapezius and levator scapulae, with a trigger point in the upper trapezius that reproduces her pain. Restricted C5-C6 on the right, and T3-T5. Spurling’s test negative on both sides; cervical distraction eases the neck pain. Shoulder range of motion full and pain-free; Hawkins-Kennedy and Neer tests negative. Strength, sensation, and reflexes C5 to T1 normal; Hoffmann’s sign negative.
Imaging
Not indicated: no trauma, red flags, or neurological deficit. No prior imaging.
Diagnosis
Mechanical neck pain with right upper trapezius myofascial pain, and segmental dysfunction at C5-C6 and T3-T5, linked to her workstation. Cervical radiculopathy unlikely: no arm symptoms, Spurling’s negative, and a normal neurological exam. Shoulder impingement unlikely: shoulder tests negative. Prognosis good.
Informed consent
Explained spinal manipulation, mobilization, soft tissue work, and exercise. Discussed common short-lived soreness or stiffness, and rare serious risks, including stroke, which has been associated with neck manipulation. Alternatives: exercise alone, physical therapy, medication through her physician, or no treatment. Questions answered; written consent signed.
Treatment plan
Today: prone diversified adjustment to T3-T5, supine diversified adjustment to C5-C6, and soft tissue work to the right upper trapezius, 8 minutes. Twice a week for 2 weeks, then weekly for 4 weeks. Short-term goals, 3 weeks: neck pain 3/10 or less at the end of the workday; right rotation 70° or more. Long-term goals, 6 weeks: full workdays with pain 2/10 or less; Neck Disability Index under 10%; back to weekly yoga. Self-care: chin tucks and shoulder blade squeezes twice a day; laptop raised to eye level, with a separate keyboard and mouse; a short break every 30 minutes. Re-exam at 6 weeks. No co-management needed now.
Chiropractic initial exam: hip and low back pain in a runner
Chiropractic clinic, new patient
History
52-year-old man, recreational runner, self-referred. Left low back and buttock pain for 3 weeks, after raising his weekly distance from 25 to 40 km (16 to 25 mi) for a half marathon. 3/10 at rest and 6/10 after running 5 km (3 mi); eases with walking. Stiff for 15 minutes in the morning. No groin pain, numbness, tingling, or leg weakness. Two short episodes of low back pain in the past, each settled within a week. Healthy; no regular medications. Oswestry 18%. Goal: run his half marathon in 10 weeks.
Red flag screen
Age over 50 noted. No history of cancer, unexplained weight loss, fever, night pain, trauma, or steroid use. No saddle numbness, bladder or bowel changes, or progressive weakness. No other red flags.
Examination
BP 128/80, pulse 58. Height 180 cm (71 in), weight 78 kg (172 lb). Normal gait. Standing on the left leg, the pelvis drops on the right: Trendelenburg sign positive on the left. Lumbar flexion full; extension about 75%, with left low back pain. Tender left sacroiliac joint and left gluteus medius; hypertonic left lumbar paraspinals. Restricted left sacroiliac joint and L5-S1. Sacroiliac provocation: thigh thrust, compression, and sacral thrust positive on the left; distraction negative. FABER reproduces left buttock pain. Hip range of motion full and pain-free on both sides; FADIR negative. Straight-leg raise and slump tests negative. Left hip abduction 4/5; other myotomes, sensation, and reflexes L4 to S1 normal.
Imaging
Not indicated: no trauma, red flags, or neurological deficit, and the hip exam is normal. Will reconsider if not improving by the re-exam. No prior imaging.
Diagnosis
Left sacroiliac joint pain with L5-S1 segmental dysfunction, after a rapid increase in running load, with left hip abductor weakness. Lumbar radiculopathy unlikely: nerve tension tests and neurological exam normal. Hip joint problem unlikely: hip motion full and pain-free. Stress fracture unlikely: no bony tenderness or night pain. Prognosis good if running load is adjusted.
Informed consent
Explained lumbar and sacroiliac manipulation, soft tissue work, and exercise. Discussed common short-lived soreness, and rare serious risks, such as worsening of a disc injury. Alternatives: exercise and load changes alone, physical therapy, or no treatment. Questions answered; written consent signed.
Treatment plan
Today: side-posture diversified adjustment to the left sacroiliac joint and L5-S1, and soft tissue work to the left gluteals, 8 minutes. Twice a week for 2 weeks, then weekly for 4 weeks. Running: cut to 20 km (12 mi) a week at an easy pace, with no hills or speed work, for 2 weeks; then add about 10% a week if pain stays at 2/10 or less during runs and the next morning. Short-term goals, 3 weeks: run 5 km (3 mi) with pain 2/10 or less; level pelvis standing on the left leg. Long-term goals, 6 weeks: Oswestry under 10%; back to full half-marathon training. Self-care: side-lying hip abduction, glute bridges, and side planks, daily. Re-exam at 6 weeks. No co-management needed now.
What goes in each part.
History
The story of the complaint, and the context that shapes your plan.
- Onset and mechanism
- Pain rating, quality, radiation, and pattern
- Previous episodes, imaging, and care
- Health history, medications, and bone health
- Function, a baseline outcome measure, and the patient’s goals
Avoid: Leaving out the patient’s own goals. They anchor the treatment plan and the discharge decision.
Red flag screen
A record of each warning sign you asked about, and what you did with the answers.
- Signs of cancer, infection, or fracture
- Signs of cauda equina syndrome or progressive nerve compromise
- For neck complaints, cervical artery warning signs
- The outcome, and any referral made
Avoid: A single “red flags negative.” List what you asked, so a reader can see the screen was done.
Examination
Findings that confirm or rule out your working diagnosis, recorded so the re-exam can repeat them.
- Vital signs, height, and weight
- Posture, gait, and active range of motion
- Palpation and motion palpation by level
- Orthopedic tests by name, side, and result
- Dermatomes, myotomes, and reflexes
Avoid: Tests without a side or a result. “Kemp’s positive” needs the side and what it reproduced.
Diagnosis
Your working diagnosis by region, the findings behind it, and what else you considered.
- Diagnosis by region
- Supporting findings
- Differential diagnoses, and why they are less likely
- Prognosis, and factors that may slow recovery
Avoid: A diagnosis without a differential. Showing what you ruled out shows your reasoning.
Informed consent
The conversation, not just the form: what you proposed, the risks and alternatives, and the patient’s agreement.
- The proposed care, in plain words
- Common risks and rare serious risks
- Alternatives, including no care
- Questions answered, and how consent was given
Avoid: Relying on a signed form alone. Note that you explained the risks of this patient’s care.
Treatment plan
What you will do, how often, for how long, and how you will know it worked.
- Today’s treatment
- Visit frequency and duration
- Measurable short- and long-term goals
- Self-care and activity advice
- The re-exam date, and any co-management
Avoid: Open-ended care. A plan needs a frequency, a duration, and a re-exam date.
Common mistakes, and how to avoid them.
Imaging every new patient
Routine X-rays add radiation without changing care for most spinal pain. Record why imaging is or isn’t indicated: red flags, significant trauma, a neurological deficit, or failure to improve.
No baseline to compare with
The re-exam can only show change against day one. Record pain, range of motion in degrees, and a named outcome measure such as the Oswestry or Neck Disability Index.
Consent that leaves out neck risks
Patients having neck manipulation should hear about its rare association with stroke. Record that you discussed it, along with the alternatives.
Goals the re-exam can’t measure
“Feel better” can’t be re-examined. Use pain ratings, degrees of motion, outcome scores, and functional targets with time frames.
Not referring when the exam points elsewhere
When findings suggest a fracture, infection, cancer, or progressive nerve loss, refer, and write down where, why, and how urgently.
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Frequently asked questions.
What should a chiropractic initial exam include?
The history and the patient’s goals, a red flag screen, posture, range of motion, palpation, orthopedic and neurological tests, the imaging decision, a diagnosis with a differential, informed consent, and a treatment plan with goals and a re-exam date.
Which red flags should a chiropractor screen for?
Signs of cancer, infection, fracture, and cauda equina syndrome, such as a cancer history, fever, trauma, saddle numbness, or bladder or bowel changes. For neck complaints, add cervical artery warning signs: dizziness, double vision, trouble speaking or swallowing, and sudden severe headache.
Does every new chiropractic patient need X-rays?
No. Imaging is usually reserved for red flags, significant trauma, a neurological deficit, or pain that doesn’t improve with care. Record the reason either way.
How do I document informed consent for chiropractic care?
Record that you explained the proposed care, its common and rare material risks, the benefits, and the alternatives, including no care; that the patient’s questions were answered; and whether consent was verbal or written. Follow your regulator’s guidance.
Is this chiropractic initial exam template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More chiropractic templates, and guides.
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Visit note with segmental findings, adjustments by region and technique, and response to care.
Chiropractic re-exam note template
Formal reassessment against the initial exam, with outcome scores and a continue, taper, or refer decision.
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Vero for chiropractic
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Your template. Filled in from the visit.
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