NEW PATIENT FORM | Roc Integrated Med

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

Address

City

Employer Name

Spouse or Patient's Guardian Name

Last Name

Date of Birth

Status

Minor

Single

Married

Divorced

Widowed

Separated

Sex

Male

Female

State

Zip Code

Employer Address

Whom May We Thank For Referring You?

Contact Information

Person to Contact in Case of an Emergency

Cell Phone

Primary Care Physician Name

Primary Care Phone Number

Relationship to Emergency Contact

Insurance Information

Do You Have Insurance?

Yes

No

(If yes, complete the following:)

Insurance Company

Name of the Subscriber

Relationship to Patient

Insurance Company Address

City

Group Number

ID Number

Birthdate of the Subscriber

Effective Date

State

Zip Code

Health History

Height

Weight

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

Wrist/Hand Pain?

Yes

No

Elbow Pain?

Yes

No

Shoulder?

Yes

No

Hip Pain?

Yes

No

Knee Pain?

Yes

No

Ankle/Foot Pain?

Yes

No

Joint Pain?

Yes

No

High Blood Pressure?

Yes

No

Arthritis?

Yes

No

Asthma?

Yes

No

Cancer?

Yes

No

Stroke?

Yes

No

Aids & HIV?

Yes

No

Fatigue?

Yes

No

Lightheadedness?

Yes

No

Feeling Foggy?

Yes

No

Osteoporosis?

Yes

No

Anemia?

Yes

No

Chronic Cough

Yes

No

Chest Congestion?

Yes

No

Itchy/Watery Eyes?

Yes

No

Shortness of Breath?

Yes

No

Wheezing?

Yes

No

Dizziness?

Yes

No

Numbness?

Yes

No

Tingling?

Yes

No

Hepatitis?

Yes

No

Implants?

Yes

No

Migraine Headaches?

Yes

No

Bleeding Tendency?

Yes

No

Diabetes?

Yes

No

Heart Conditions?

Yes

No

Weakness/Tiredness?

Yes

No

Irritability?

Yes

No

Forgetfulness?

Yes

No

Any Other Disease?

Yes

No

When?

Condition Treated?

Hospital, City, State

Medications

Known Allergies

Family Medical History

Patient Social History

Who do you Live With?

Use of Alcohol

Never

Rarely

Moderate

Daily

Use of Tobacco

Never

Rarely

Moderate

Daily

Use of Drugs

Never

Type/Frequency

Occupation

Name of Employer

Occupation

I am Currently

Full Time

Part Time

Unemployed

Student

Motor Vehicle Accident ONLY

Date of Accident

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 you Lose Consciousness?

Yes

No

If Yes, For How Long?

List the Other People in the Vehicle

Did you Go into Emergency Room After the Accident?

Yes

No

If Yes, Where?

Location of the Accident

Make & Model of Other Vehicle Involved

Where on the Vehicle Did the Impact Occur?

Driver's Side

Passenger Side

Front

Rear

Did the Airbags Deploy?

Yes

No

Were you Wearing a Seatbelt?

Yes

No

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

Yes

No

If Yes, Please Describe

Was Your Vehicle Towed from the Scene?

Yes

No

Approximate Damage $

If Yes, How Did You Get There?

Ambulance

Private Transportation

Workers Comp Injury ONLY

Date of Injury

Employer at Time of Injury

Your Job Title

Approximate Time of Injury

Who Did You Report The Injury To?

Their Job Title

Please Describe How The Injury Occurred

Did you Go into Emergency Room After the Accident?

Yes

No

If Yes, Where?

Are you Able to Work?

Yes

No

If No, Since When?

If Yes, How Did You Get There?

Ambulance

Private Transport

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need. I agree to receive appointment reminders via text or email.

Previous Hospitalizations, Surgeries, Serious Illnesses not related?

Contact Us

309 Exchange Blvd Ste A Rochester, NY 14608

Tel: 585-454-4190