Patient Intake Form

Status
Sex

Contact Information

Insurance Information

Do You Have Insurance?

(If yes, complete the following:)

Health History

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?
Wrist/Hand Pain?
Elbow Pain?
Shoulder?
Hip Pain?
Knee Pain?
Ankle/Foot Pain?
Joint Pain?
High Blood Pressure?
Arthritis?
Asthma?
Cancer?
Stroke?
Aids & HIV?
Fatigue?
Lightheadedness?
Feeling Foggy?
Osteoporosis?
Anemia?
Chronic Cough
Chest Congestion?
Itchy/Watery Eyes?
Shortness of Breath?
Wheezing?
Dizziness?
Numbness?
Tingling?
Hepatitis?
Implants?
Migraine Headaches?
Bleeding Tendency?
Diabetes?
Heart Conditions?
Weakness/Tiredness?
Irritability?
Forgetfulness?
Any Other Disease?

Patient Social History

Use of Alcohol
Use of Tobacco
Use of Drugs

Occupation

I am Currently

Motor Vehicle Accident ONLY

Where Were You in The Vehicle?
Did you Lose Consciousness?
Did you Go into Emergency Room After the Accident?
Where on the Vehicle Did the Impact Occur?
Did the Airbags Deploy?
Were you Wearing a Seatbelt?
Did Your Vehicle Strike any Other Object? (Ex. Tree, Pole)
Was Your Vehicle Towed from the Scene?
If Yes, How Did You Get There?

Workers Comp Injury ONLY

Did you Go into Emergency Room After the Accident?
Are you Able to Work?
If Yes, How Did You Get There?

Previous Hospitalizations, Surgeries, Serious Illnesses not related?