Patient Information
Today's Date
*
/
Month
/
Day
Year
Date
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
/
Month
/
Day
Year
Date of Birth
Social Security Number
*
Gender
Please Select
Male
Female
Prefer not to say
Patient Phone Number
*
Please enter a valid phone number.
Email Address
example@example.com
Address
*
Street Address
Apartment Number
City
Please Select
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
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Mississippi
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New York
North Carolina
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Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Referring Doctor or Attorney
*
Referring Phone Number
Please enter a valid phone number.
Are you still working?
*
Please Select
Yes
No
Full-Time or Part-Time
Full-Time
Part-Time
Last Day at Work
*
/
Month
/
Day
Year
Date
Emergency Contact Information
Emergency Contact Name
*
Relation
Please Select
Spouse
Parent
Sibling
Child
Uncle
Aunt
Friend
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Worker's Compensation Insurance Information
Worker's Compensation Carrier
Date of Injury
*
/
Month
/
Day
Year
Date
Did you report this accident to your employer?
*
Yes
No
Carrier Claim Number
Workers Compensation Board (WCB) Number
Other
Employer
Employer Phone Number
Please enter a valid phone number.
Attorney Name
Attorney Phone Number
Please enter a valid phone number.
Pharmacy
*
What is the most convenient pharmacy for you to pick up medication?
Pharmacy Phone Number
*
Please enter a valid phone number.
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Medical History
Diabetes
Self
Famliy
High Cholesterol
Self
Family
Hypertension
Self
Family
Strokes
Self
Family
Heart Problems
Self
Family
Cancer
Self
Family
Asthma
Self
Family
Seizures
Self
Family
Other Medical History
Surgical History
Have you had any prior surgeries the Doctor should know about?
Yes
No
Year(s)
2021
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Prior to 1990
Procedure(s)
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Height (Inches)
*
Weight (Lbs)
*
Please list any allergies you may have:
Are you currently taking non-prescription drugs?
*
Yes
No
Please specify which non-prescription drugs:
Are you currently taking prescription drugs?
*
Yes
No
Please specify which prescription drugs:
Do you smoke?
*
Yes
No
How many packs per day?
Do you drink?
*
Yes
No
How often?
How long have you had this injury/problem?
Was this the result of a fall or accident?
Yes
No
Date of Fall or Accident
/
Month
/
Day
Year
Date
Can you perform normal activities?
Yes
No
Are there any restrictions?
Check the symptoms associated with your chief complaint:
Pain
Numbness
Tingling
Weakness
Muscle Spasm
Other
Please indicate where you feel pain or symptoms:
*
Head
Neck
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Left Hand
Right Hand
Left Hip
Right Hip
Left Knee
Right Knee
Left Foot
Right Foot
Other
How severe is the pain at onset? (5 being the worst)
Please Select
0
1
2
3
4
5
How severe is the pain today? (5 being the worst)
Please Select
0
1
2
3
4
5
How bad is the pain?
Please Select
0 - No Hurt
2 - Hurts a little bit
4 - Hurts a little more
6 - Hurts even more
8 - Hurts a whole lot
10 - Hurts worst
What is the quality of the pain?
Sharp
Shooting
Stabbing
Dull
Aching
Intermittent
Constant
Other
What makes your problem worse? (Check all that apply)
Standing
Sitting
Walking
Lifting
Exercise
Twisting
Lying Down
Squatting
Kneeling
Bending
Coughing
Sneezing
Other
What treatments have you had for this problem? (Check all that apply)
Epidural Injections
Physical Therapy
Massage
Stimulation (TEN)
Acupuncture
Trigger Point Injections
Brace
Other
Do you have: (Check all that apply)
MRI Report/Films
X-Ray Films
EMG (Nerve conduction studies)
CT Scans
Disco Gram
Bone Scan
Other
What medications have you tried for this condition?
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