NEW PATIENT FORM | Roc Integrated Med

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309 Exchange Blvd Ste A Rochester, NY 14608

Tel: 585-454-4190

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Patient Intake Form

First Name

SS #/SIN

Cell Phone

Email

Address

City

Last Name

Date of Birth

Status

Minor

Single

Married

Divorced

Widowed

Separated

Sex

Male

Female

Height

Weight

State

Zip Code

Occupation

Employer Name

Emergency Contact

Emergency Contact Cell Phone

Employer Address

Relation to Emergency Contact

Primary Care Physician Name

Primary Care Phone Number

Do You Have Medical Insurance?

Yes

No

(If yes, complete the following:)

Medical Insurance Company

Medical Insurance ID Number

Relationship to Patient

Medical Insurance Group Number

Name of the Subscriber

Birthdate of the Subscriber

Whom May We Thank For Referring You?

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?

Yes

No

Low Back Pain?

Yes

No

Elbow Pain?

Yes

No

Hip Pain?

Yes

No

Knee Pain?

Yes

No

Numbness?

Yes

No

Implants?

Yes

No

Any other Disease?

Hospitalizations:

Known Allergies

MidBack Pain?

Yes

No

Shoulder Pain?

Yes

No

Hand Pain?

Yes

No

Leg Pain?

Yes

No

Ankle/Foot Pain?

Yes

No

Weakness

Yes

No

Cancer?

Yes

No

Any Other Conditions?

Medications

Family Medical History

Who do you Live With?

AUTO CRASHES ONLY

Date of Crash

Auto Insurance

Make & Model of Vehicle you Were In

Where Were You in The Vehicle?

Driver's Seat

Passenger Seat

Rear Driver's Side

Rear Passenger Side

Rear Middle Seat

Did the Airbags Deploy?

Yes

No

Were you Wearing a Seatbelt?

Yes

No

List the Other People in the Vehicle

Was Your Vehicle Towed from the Scene?

Yes

No

Did you Go to the Hospital after the Crash?

Yes

No

Location of the Accident

Claim Number

Make & Model of Other Vehicle Involved

Where on the Vehicle Did the Impact Occur?

Driver's Side

Passenger Side

Front

Rear

Did you Lose Consciousness?

Yes

No

Did Your Vehicle Strike any Other Object? (Ex. Tree, Pole)

Yes

No

If Yes, Please Describe

Approximate Damage Amount

If Yes, Where?

Attorney Representing Me

WORKERS COMP CASES ONLY

Date of Injury

Work Comp Claim Number

Your Job Title

Who Did You Report The Injury To?

Work Comp Insurance Company

Employer at Time of Injury

Approximate Time of Injury

Any Other Doctors treat you for this Injury?

Please Describe How The Injury Occurred

Are you Working or Missing Work?

If Missing, Since When?

Attorney Representing Name

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous for me and misleading to my health care providers. I agree to accept text messages regarding my initial appointment.

309 Exchange Blvd Ste A Rochester, NY 14608

Tel: 585-454-4190

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