Telemedicine Visit intake form

Name* This field is required.

First Name

Last Name

When would you like to meet ? Pick 1 or 2 dates and times that are convenient for you and we will text you a link for the visit * This field is required.

Date of Birth* This field is required.

Date

Email (required so we can set you up for telerehab)* This field is required.

example@example.com

Cell Phone Number * This field is required.

Area Code

Phone Number

Date of Injury

Date

What is your dominant hand?* This field is required.

Right

Left

Ambidextrous

Have you ever had any difficulties prior to the date of your injury that were similar to those you are now experiencing?

YESNO

Please describe how your injury occurred:* This field is required.

What problems did you have at that time?* This field is required.

Briefly describe what has occurred since that time to this date:* This field is required.

What is your greatest concern at this time?* This field is required.

Where is your pain located?* This field is required.

How would you describe your pain?* This field is required.

What makes your pain worse?* This field is required.

What makes your pain better?* This field is required.

We would like to ask you about your pain . In answering these questions: 0 is pain free ....1 – Pain is very mild, barely noticeable. Most of the time you don’t think about it.....* This field is required.

Do you have any of the following conditions? Select all that apply* This field is required.

Depression or PTSD

Use Opiods

Diabetes

Obesity

Substance Abuse

High Blood Pressure

Smoker

I had surgery for this problem

I have been in the hospital for this problem

I have hired an attorney for this case

None of the above apply to me

Please tell us your Weight (lbs) and Height (feet and Inches)* This field is required.

Please list any tasks that are difficult for you to perform:* This field is required.

What is your level of education?* This field is required.

Are you working now (Please describe if applicable)?* This field is required.

Please describe your typical day:* This field is required.

Please describe any significant recreational pursuits you are involved with:* This field is required.

Do you smoke?* This field is required.

YESNO

How many alcoholic beverages do you have per week?* This field is required.

Please list any medical hospitalizations:* This field is required.

Please list any operations you have had:* This field is required.

Please list any medications you are currently taking:* This field is required.

Please list any medication allergies that you have:* This field is required.

Have you had any other medical problems?* This field is required.

Do you know of any diseases run in your family? If yes please list.

Please provide any other comments that may assist us in understanding your situation:* This field is required.

Please upload any files to help us better understand your case. These may include photographs taken around the time of injury or anything else you would like to show us.

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Max. file size: 10.6MB