PATIENT INTAKE FORM

PLEASE ASSIST US IN PLANNING YOUR CARE BY FILLING OUT THE FOLLOWING SURVEY AS COMPLETELY AS POSSIBLE. THANK YOU.

PATIENT INFORMATION

First Namerequired
Last Namerequired
Date of Birthrequired
Genderrequired

How would you like to be addressed?textoptionaldb save

Emailtextrequireddb save
Work Phonenumberrequireddb save
Home Phonenumberrequireddb save

Addressrequired
Cityrequired
Staterequired
Ziprequired

Marital Statustextoptionaldb save

Primary Care Physiciantextoptionaldb save
Phone Numbernumberoptionaldb save

Who referred you?textoptionaldb save

EMERGENCY CONTACT INFORMATION

Emergency Contact Nametextrequireddb save
Contact Relationshiptextoptionalnot save
Contact Phonenumberrequireddb save

MEDICAL HISTORY

What is your primary reason for seeing the doctor today? Mark all that apply:

Increase of local blood flow
Decrease of muscle soreness and stiffness
Moderation of pain
Facilitation of relaxation
Prevention or elimination of adhesions

For how long have you had this problem or when did you first notice this problem?textoptionaldb save
Please list any medical problems that you havetextoptionaldb save
Please list all surgical procedures that you have had (include dates if known)textoptionaldb save
Please list all medications (including prescription, other-the-counter, vitamins, herbal supplements) you are currently takingtextoptionaldb save
Please list all ALLERGIES you have to any medications (with reactions)textoptionaldb save

Current Heightnumberrequireddb save
Current Weightnumberrequireddb save
Maximum Adult Weightnumberrequireddb save

When was the last time you saw your primary care physician?textoptionaldb save
Please list any medical conditions that your family members have had (high blood pressure, diabetes, blood clots, cancer)textoptionaldb save

SMOKING HISTORY


requireddb save
Have you ever smoked cigarettes?

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Do you currently smoke cigarettes?

How many packs per day?numberoptionaldb save
When did you start smoking?textoptionaldb save
When did you stop smoking?textoptionaldb save

requireddb save
Are you using nicotine patches or gum?

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Do you smoke pipes, cigars, or chew tobacco?

ALCOHOL HISTORY


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Do you drink alcohol?
How many alcoholic drinks do you consume in 1 week (1 beer + 1 drink)?textoptionaldb save

REVIEW OF SYSTEMS

Please check all that currently apply

GENERAL

Weight Changes
Easy Bruising
Fatigue
Prolonged Bleeding
Fevers
Healing Problems
Chills
Blood Clots

NOSE/SINUS

Prior Nose Surgery
Prior Nose Trauma
Sinus Allergies
Nighttime Snoring
Difficulty Breathing through Nose
Sleep Apnea
Sinus Infections
Voice Changes

ENDOCRINE

Diabetes
Cold Finger or Toes
Thyroid Disorder
Heat Intolerance
Cold Intolerance

INFECTIONS

HIV/AIDS
Hepatitis

MOUTH/TEETH

Dental Infection
Dental Crowns/Caps
Previous Oral Surgery
Oral Cancer
Dental Implants
Wear Dentures

LUNGS/PULMONARY

Asthma
COPD
Bronchitis
Pneumonia
Shortness of Breath
Emphysema
Persistent Cough
Pulmonary Embolism
Coughing Up Blood
Tuberculosis (TB)

EYES

Eye Pain
Eye Irritation
Contact Lenses
Excessive Tearing
Visual Changes
Glaucoma
Double Vision
Eye Light Sensitivity

BREAST

Breast Mass
Nipple Discharge
Prior Breast Biopsy
Fibrocystic Breast Disease
Heavy Menses
Tender Breast

STOMACH/INTESTINAL

Stomach Reflux
Black or Tarry Stool
Diarrhea
Hepatitis
Stomach Ulcer Disease
Constipation
Cirrhosis

EARS

Ear Pain

HEART/CARDIOVASCULAR

Irregular Heart Beat
Prior Angiogram
Non-Healing Leg Wounds
Previous Blood Transfusion
High Blood Pressure
Pacemaker
Murmur
Heart Attack
Prior Heart Surgery

UROLOGIC

Difficulty Urinating
Incontinence
Persistent Flank Pain

MUSCULOSKELETAL

Join Pain/Arthritis
Back Pain
Bone Pain
Neck Pain
Leg Cramping
Difficulty Walking

PSYCHIATRIC

Depression
Alcoholism
Drug Use
Anxiety
Bipolar Disease

NEUROLOGIC

Seizures
Headaches
Prior Head Injury
Stroke or TIA
Problems with Balance
Dizzy Spells
Migraine Headaches
Tremors
Memory Loss
Trouble Concentrating

The information I have given above is complete and accurate. As with all medical records, the information provided will be confidential.


Date: 9/7/2020

Time: 1:18 AM

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