Language
English (US)
Spanish (Latin America)
Demographics
Photo Identification
*
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Government Form of ID
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Full Name:
*
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Social Security Number:
Gender
*
Male
Female
Other
Mobile Phone Number:
*
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
Email:
*
example@example.com
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Information
Martial Status
Single
Married
Legally Separated
Divorced
Widowed
Other
If Married: Name of Spouse
First Name
Last Name
If Married: Cell Phone Number of Spouse
-
Area Code
Phone Number
Name of Emergency Contact
First Name
Last Name
Relationship to Patient:
Mobile Number
-
Area Code
Phone Number
Primary Care Physician (Name, Contact Information)
Pharmacy Information (Name, Address, Phone)
How did you hear about us?
*
If you were referred from another physician please note their name
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Insurance Information
Insurance Card
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Upload pictures of Front and Back of your Insurance Card
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Primary Insurance Carrier Name:
ie. Horizon
Claim/ID#:
Group #:
Policy Holder Name:
First Name
Last Name
Relationship to Patient:
Policy Card Holder Date of Birth:
-
Month
-
Day
Year
Date
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Employment Information
Occupation
Name of Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Number
-
Area Code
Phone Number
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Accident Information
Fill out this section if you are being evaluated related to a Motor Vehicle Accident or a Work Related Injury
Is this appointment related to an accident sustained in a vehicle or work?
*
YES
NO
Are you currently working?
Yes
No
To what extent are you working?
Full-time
Light Duty
Modified Duty
Not working
Last Day Worked:
-
Month
-
Day
Year
Date
Did your accident occur during work hours?
Yes
No
Type of Accident
Auto - Motor Vehicle
Work Related - Motor Vehicle
Work Related
Other
Accident Date:
-
Month
-
Day
Year
Date
State in which accident occurred?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Attorney Information
Please include attorney name, contact
Attorney Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney's Phone Number
-
Area Code
Phone Number
Attorney Fax Number:
-
Area Code
Phone Number
Attorney Email:
example@example.com
Please provide a detailed description of your accident:
Name of Workers Compensation/Auto Injury Insurance Company
Claim or WCB#:
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HISTORY OF PRESENT ILLNESS
Areas of pain & symptoms
Brief history of your symptoms
*
When did your symptoms begin?
*
-
Month
-
Day
Year
Date
Pain Scale
*
0
1
2
3
4
5
6
7
8
9
10
No Pain
Severe Pain
0 is No Pain, 10 is Severe Pain
Location of Pain
Annotate Image
Where on your body do you have discomfort?
Left
Right
Both
Head
Neck
Mid-back
Low back
Shoulder
Elbow
Wrist
Hand
Chest
Ribs
Abdomen
Pelvis
Hip
Knee
Ankle
Foot
Indicate Type of Discomfort:
Yes
No
Sharp
Stabbing
Throbbing
Dull
Pressure
Burning
Stiffness
Weakness
Spasm
Numbness/Tingling
If other, please explain
Have you treated with other doctors for this problem?
Yes
No
If yes, where?
Please include name, number and address
Have you had any physical therapy for this problem?
Yes
No
If yes, where?
Upload prior medical records (Physician, Podiatrist, Chiropractic, Physical Therapist, Occupational Therapist)
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Please upload all pertinent documentation
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Have you had any radiological studies performed (MRIs, CT Scans or X-Rays)?
Yes
No
If yes, please explain?
Include information what study was performed, which body part, date performed, and where it was performed
Upload radiological studies
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Review of Symptoms
Please check any boxes of the symptoms you are experience both related to the chief complaint and unrelated
Review of Symptoms
Cramping
Spasm
Restricted Motion
Joint Swelling
Numbness
Tingling
Weakness
Fevers
Chills
Night Sweats
Weight Gain
Weight Loss
Fatigue
Headaches
Dizziness
Blurry Vision/Double Vision
Sensitivity to Light
Loss of Hearing
Ringing in the Ears
Ear Pain
Throat Pain
Cough
Shortness of Breath
Chest pain
Palpitations
Abdominal Pain
Nausea
Vomiting
Diarrhea
Constipation
Rectal bleeding
Loss of Appetite
Tremors
Seizures
Memory loss
Loss of Consciousness
Bowel/Bladder Incontinence
Balance Problems - Trouble Walking
Numbness in the Groin Region
Trouble Sleeping at Right
Depression
Disorientation
Mental Fog
Rashes
Wounds
Skin Colour Changes
Incontinence
Pain during sex
Blood in Urine
Infections
Redness of skin
Skin Infection (Abscess/Boil/Cellulitis)
Hives
Seasonal allergies
Excessive thirst
Heat Intolerance
Cold Intolerance
Easy Bruising
Bleeding gums
Increased bleeding
Edema (Swelling of Legs)
General
Fevers
Chills
Night Sweats
Weight Gain
Weight Loss
Fatigue
Constitutional
Head/Eyes/Ears/Nose/Throat
Headaches
Dizziness
Blurry Vision/Double Vision
Sensitivity to Light
Loss of Hearing
Ringing of the Ears
Ear Pain
Trouble Swallowing
HEENT
Lungs
Cough
Shortness of Breath
Respiratory
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Past Medical/Surgical/Social History
Medical Problems - Please check all that apply
*
No active or past medical history
Neck or Back Pain
Osteoarthritis
Osteoporosis
Neck or Back Disc Disease
Rheumatoid Arthritis
Psoriatic Arthritis
Spinal Fracture
Headaches/Migraines
Diabetes
High Blood Pressure
Heart Disease
Stroke/CVA
Hemiplegia
Blood Clots
Heart Failure
Chest Pain
Heart Attack (Myocardial Infarction)
Peripheral Vascular Disease
Thyroid Disease
Asthma
COPD
Pneumonia
Tuberculosis
COVID-19
Anemia
Bleeding Disorders
Cancer
Depression
Bipolar Disorder
Substance Abuse
Sleep Apnea
Restless Leg Syndrome
Chronic UTI
GERD
Irritable Bowel Syndrome
Lupus/SLE
Immune Disorder
Head Injury (TBI/Concussion/CTE)
Paralysis
Cerebral Palsy
Dementia
Alzheimer's Disease
Parkinson's Disease
Seizure Disorder
Diabetic Neuropathy
Nerve Injury
HIV/AIDs
MRSA
Hepatitis
Fibromyalgia
Kidney Disease
Prior Gun Shot
Other
Please enter your height (feet/inches)/weight(pounds)
Past surgeries and procedures - Please check all that apply
*
No prior surgeries or procedures
Nerve Injections
Joint Injections
Facet Injections
Epidural Injections
Discectomy
Spinal Fusion
Kyphoplasty/Vertibroplasty
Knee Replacement
Knee Arthroscopy
Shoulder Arthroscopy
Hip Arthroscopy
Hernia Repair
Gallbladder Removal
Implanted Defibrillator
Cardiac Stent
Heart Valve Implants
Metal Implants
Botox Injection
Beauty/Aesthetic/Cosmetic Surgery
Other
If other medical or surgical history, please include here
Are you on any blood thinners?
*
Yes
No
If yes, please specify:
Medications (Please include supplements):
*
Please include Name Dose and Frequency
Allergies
*
No Known Drug Allergies
IV dye/contrast
Iodine
Shellfish
Penicillin
Sulfa- drugs
Erythromycin
Ibuprofen
Aspirin
Cipro
Latex
Adhesive
Other
Please explain what type of reaction you have? If other please explain
Are you vaccinated for COVID?
*
Yes
No
Please upload you vaccine card here
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Social History
Do you use Tobacco?
*
Yes
No
If Yes, clarify which form of tobacco
Cigarettes
Cigars
Hookah
Chewing Tobacco
Do you drink Alcohol excessively?
Yes
No
Do you use cannabis/marijuana
Yes
No
Do you use Illicit Drugs?
Yes
No
If Yes, please explain:
Pregnant
*
Yes
No
Diet
If you have a special diet or avoid certain foods please explain
Are you interested in Medical Weight Loss?
*
Yes
No
Family History
Does anyone in your immediate family diagnosed with the following:
Hypertension
Diabetes
Heart Disease
Cancer
Nerve or Muscle Disease
Fibromyalgia
Depression
Bipolar Disorder
Substance Abuse
If other please list or elaborate on the above.
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