Patient Intake Form

Status
Sex
Do You Have Medical Insurance?

(If yes, complete the following:)

Chief Complaints

Past Medical History

Do you or have you ever had the following? (select 'yes' or 'no' / leave blank if you are uncertain

Neck Pain?
Low Back Pain?
Elbow Pain?
Hip Pain?
Knee Pain?
Numbness?
Implants?
MidBack Pain?
Shoulder Pain?
Hand Pain?
Leg Pain?
Ankle/Foot Pain?
Weakness
Cancer?

AUTO CRASHES ONLY

Where Were You in The Vehicle?
Did the Airbags Deploy?
Were you Wearing a Seatbelt?
Was Your Vehicle Towed from the Scene?
Did you Go to the Hospital after the Crash?
Where on the Vehicle Did the Impact Occur?
Did you Lose Consciousness?
Did Your Vehicle Strike any Other Object? (Ex. Tree, Pole)

WORKERS COMP CASES ONLY