New Patient Intake Form

New Patient Intake Form
Name*

First NameLast Name
Nickname
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Date
Age:*
Sex:

FemaleMale
Marital Status

SingleMarriedDomestic PartnerWidowedDivorced
Name of Significant Other
Emergency Contact*
Phone Number*
How did you hear about our office?*
Reason for today's visit
Primary Complaint - what brings you in today? *
When did this start?*
Was there a specific event/injury?*
What makes it worse?
What makes it better?
How would you describe the pain?*

AchyBurningColdCrampingHeavyHotNumbPins and NeedlesRadiatesSharpShocksStabbingSwollenThrobbingTinglingTravelsOther
How would you rate the pain now from 0 (best) to 10 (worst):
How would you rate the pain at its worst from 0 (best) to 10 (worst):
When does it bother you most?

MorningMiddayNightConsistent all day
Is the pain:
Any other health professional seen for this problem:
What treatments have you tried?

AspirinAleveTylenolIbuprofenMotrinGabapentinLyricaCymbaltaNeurontinPhysical TherapyChiropractorMassageCreamsInjectionsSurgeryOther
What treatments helped?
Does it interfere with:

FamilyRelationshipsWorkExerciseRecreational ActivitiesSleepOther
What specific activities does this problem prevent you from doing, either partially or totally, that you would like to be able to do again?
On a scale of 1-10, 10 being the most, rate your level of commitment to getting rid of this problem:
What do you do in a typical day?
What would be your #1 goal from visiting the clinic?
Secondary Complaint
What else brings you in today?
When did this start?
Was there a specific event/injury?
What makes it worse?
What makes it better?
How would you describe the pain?

AchyBurningColdCrampingHeavyHotNumbPins and needlesRadiatesSharpShocksStabbingSwollenThrobbingTinglingTravelsOther
How would you rate the pain now from 0 (best) to 10 (worse):
When does it bother you most?

MorningMiddayNightConsistent all day
Any other health professionals seen for this problem:
What treatments have you tried?

AspirinAleveTylenolIbuprofenMotrinGabapentinLyricaCymbaltaNeurontinPhysical TherapyChiropractorMassageCreamsInjectionsSurgeryOther
What treatments helped?
Does it interfere with:

FamilyRelationshipsWorkExerciseRecreational ActivitiesSleepOther
What specific activities does this problem prevent you from doing, either partially or totally, that you would like to be able to do again?
On a scale of 1-10, 10 being the most, rate your level of committed to getting rid of this problem:
What other health problems concern you today?
Please indicate which of the below you have experienced in the last 1-2 months.
General*

FatigueMalaiseWeaknessTirednessLightheadednessIrritabilityConstipationDiarrheaDigestive IssuesFeeling foggyForgetfulnessSexual DysfunctionNoneOther
Neurological*

HeadachesMigrainesDizzinessNumbnessTinglingPins/Needles in hands/feetOther
Muscular/Skeletal*

Muscle achesFibromyalgiaArthritisLow back painNeck painWrist/hand painElbow painShoulder painHip painKnee painAnkle/foot painPain between shoulder bladesJaw painOther
Eyes/Ears/Nose/Throat/Respiratory

AsthmaStuffy NoseHay feverSore throatChronic coughChest congestionFrequent sneezingItchy/watery eyesDrainageEarache, pain, or infectionsHoarsenessItchingShortness of breathWheezingOther
Perceived Health: On a scale of 1-10 (1=poor, 10=excellent), please rate how well you are doing with the following:
Exercise:
Sleep:
Diet:
Stress level:
Water Intake:
Energy level:
Past/Present Medical History*

AIDS/HIVAllergiesAnemiaAnxietyArthritisAsthmaAutoimmune dxBalance problemsBladder infectionsBleeding tendencyCancerChronic painChicken poxCOPDDecreased bone densityDepressionDiabetesDisc issuesEczemaEpilepsyFibromyalgiaFood sensitivitiesFrequent coldsGlaucomaGoutHeartburn/refluxHeart diseaseHemorrhoidsHepatitisHerniaHigh blood pressureHigh cholesterolItchingKidney diseaseLack of energyLoss of bowel/bladder controlLiver diseaseLung diseaseMeaslesMonoMumpsPneumoniaPolioRheumatoid arthritisSciaticaSinus issuesSleep problemsSTDsStrokeTension/stressThyroid diseaseTuberculosisUlcersVascular problemsWalking problemsNoneOther
Previous hospitalizations/surgeries/serious illnesses and when?*
Traumas: Please list any accidents or traumas you have suffered (mild/major) related to this condition:*
Allergies:*
Current medical conditions you would like us to know about: *
Current Medications/supplements: *
Social History
Primary Care provider:
Occupation:
Recreational Activities:
Exercise:

YesNo
How many times a week:
Use of tobacco (smoke/chew)

YesNo
How often/much:
Use of alcohol:

YesNo
How often/much:
Use of recreational drugs:

YesNo
How often/much:
Relevant Family Medical History
Please indicate if any member of your family is deceased (parents, siblings, spouse, children): Age and the cause*
Informed Consent for Treatment/Diagnostic Testing
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of hte above listed patient. I authorize this office and it's staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.
Signature*

Clear
Date:*
For Females: Verification of Pregnancy Status
**This is to ceritify that, to the best of my knowledge, I am not pregnant, and give my permission to have diagnostic x-ray if necessary** (If you are unsure of your pregnancy status, it is very importat that you inform your care provider prior ro any diagnostic imaging.)
Signature

Clear
Date:
Release of Information
This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Name and Date of Birth of Primary Account Holder
Insurance Card (front)

Cancelof
Insurance Card (back)

Cancelof
Should be Empty:

New Patient Intake Form

Reason for today's visit

Secondary Complaint

Please indicate which of the below you have experienced in the last 1-2 months.

Perceived Health: On a scale of 1-10 (1=poor, 10=excellent), please rate how well you are doing with the following:

Social History

Relevant Family Medical History

Informed Consent for Treatment/Diagnostic Testing

For Females: Verification of Pregnancy Status

Release of Information

Insurance Information