Practice Member Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Age
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email Address
example@example.com
Preferred Method of Contact: Phone Call
Home
Cell
Text Message
Email
Employed:
Full Time
Student
Retired
Occupation
Employer
In case of Emergency
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Marital Status
M
S
D
W
Partner/Spouse’s Name
First Name
Last Name
No. of Children
Are you insured?
Yes
No
Insurance Company
Is this visit the result of a Work or Auto Injury?
Yes
No
Referred by? (Whom may we thank for the referral?)
Reason for This Visit:
Describe the reason for this visit?
*
How / When did this condition begin?
*
What makes it Better?
*
Rest
Heat
Ice
Positioning
What makes it Worse?
*
Sitting
Standing
Bending
Lifting
Does the pain:
Stay in the one spot
Travel to other areas
Indicate on the drawing below where you experience any pain/symptoms:
How often do you experience your symptoms?
*
0-25%
26-50%
51-75%
76-100%
Type of Pain:
*
Sharp
Numb
Dull
Tingly
Diffuse
Sharp with motion
Achy
Shooting with motion
Burning
Stabbing with motion
Shooting
Electric like with motion
Stiff
Using a scale 0-10 (10 being the worst), how would you rate your problem?
0
1
2
3
4
5
6
7
8
9
10
Has this condition occurred before?
Yes
No
Please explain:
Have you seen other doctors for this concern?
Yes
No
Doctor(s) Name(s)
Types of treatment
Did it Help?
Yes
No
Temporary relief
Any other recent health concerns?
Please select any Past or Present health/illness we need to know
Dizziness
Headaches
Neck Pain
Numbness in arms / legs / hands
Upper Back Pain
Ulcer
Mid Back Pain
Lower Back Pain
Pain in arms / legs / hands
Hip Pain
Jaw Pain
Hepatitis
Arthritis
Cancer
Tumors
Asthma
High Blood Pressure
Heart Attack
Stroke
Kidney Stones
Heart Surgery/Pacemaker
HIV/AIDS
Diabetes Depression
Epilepsy
General Fatigue
Liver/Gall Bladder Disorder
Pregnancy
Dermatitis/Eczema/Rash
Kidney Disorders
Prostate Problems
Allergies
Systemic Lupus/Lupus
Joint Replacements
Other
Yes
No
*Are you Pregnant?
*Are you on Birth Control?
List all current medication you are taking:
How would you rate your overall Health?
Excellent
Very Good
Good
Fair
What Type of Exercise do you do?
Strenuous
Moderate
Light
None
Please list all/any surgeries and dates:
What activities do you do at work?
Most of the day
Half the day
A little of the day
Sit
Stand
Computer Work
On the phone
What activities do you do outside of work?
Have you been hospitalized?
Yes
No
If yes why?
Have you had any significant past trauma?
Yes
No
If yes please list
What is your height?
Weight?
Patient/Witness Signature:
*
Clear
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: