New Patient Intake

ABOUT YOU

First Name

Middle Name

Last Name

Social security #:

Street Address

City

State

Zip

Cell Phone

Home Phone

Work Phone

Email address

Date of Birth

AGE:

Height

Weight

Patient's Occupation:

Patient's Employer:

Add new row

Number of Children

Spouse DOB:

Spouse's Name:

Spouse's Employer:

EMERGENCY CONTACT INFORMATION

Name

Phone

Relation to You

REFERRAL INFORMATION

Referring Physician

Contact Info

Referring Patient

Are You Working with an Attorney?

Yes No

How Did You Hear About Us?

Word of Mouth

Social Media

Direct Marketing

Internet

REASON FOR VISIT

What caused this condition?

What is the date of your scheduled appointment?

What terms describe your discomfort best? (aching, burning, tingling, etc.)

On the body diagrams to the right, please indicate your areas of symptoms by drawing in the appropriate symbols.

P - pain N - numbness W - weakness S - shooting A - aching

What activity is difficult due to this discomfort? Explain:

What aggravates this condition?

What improves this condition or gives you relief?

Who have you seen for this condition up to now?

What treatment have you received for this condition up to now?

Have you ever had any previous episodes of this condition? Yes or No, Explain:

CURRENT HEALTH

Other than the information already provided, do you have additional health concerns involving any of the following?

Explain:

WORK AND SOCIAL HABITS

Current work habits: select all that apply

Permanently fully disabled

Permanently partially disabled

Cannot work due to current condition

Full-time (20-40+ hours/week)

Part-time (1-19 hours/week)

Retired

Student

Homemaker

Unemployed

Personal social habits: select all that apply

Smoke or use tobacco products

Drink alcohol

Drink caffeine

Use recreational drugs

Other, to be discussed with doctor

Present Exercise habits: select all that apply

No current exercises

Exercise daily

Exercise 3+ times per week

Cannot return to exercise due to current condition

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