New Patient Consultation Intake Paperwork

All information is private and held in confidence. At no given point is information disclosed or shared without client’s written consent.
Full Name*

First NameMiddle InitialLast Name
Address*
Date*

MonthDayYear
Date of Birth*

MonthDayYear
Personal Phone Number*
Work Phone Number
E-mail*
example@example.com
Social Security #
Driver's License #
Marital Status

SingleMarriedDivorcedWidowed
Spouse's Name
Employer & Occupation
Employer Address
How did you hear about us?

Internet SearchFamily/Friend ReferralAnother Health PractitionerSocial MediaOther
Insurance Name
ID / Member Number
Group Number
Insured's Name
Relationship to Patient

SelfSpouseChild/Dependent
Insured's DOB
Insured's Social Security #
Insured's Employer
Take a photo of your insurance card FRONT
Take a photo of your insurance card BACK
History of Present Condition
1. Chief Complaint*
2. Specific Location of Pain/Problem*
3. Quality/Description*

SharpDullStiffAchyThrobbingNumb/TinglingShootingElectric-like
4. Rate of Pain Today on a scale of 1 to 10 (1= no pain, 10= unbearable pain)*
5. Duration (for how long?)*
6. This problem is:*

Getting WorseStaying the SameGetting Better
7. Date of Onset*
What was the mechanism of injury?*
8. What activities or movements make this current condition worse?*
9. What relieves this current condition?*
10. Frequency - please select the most accurate*

Constant (75-100% of the time)Frequent (50-74% of the time)Intermittent (25-49% of the time)On and Off (1-24% of the time)RandomRecurringOther
11. Have you ever injured this area prior to this current episode?*
12. Have you ever been in an accident (automobile, work, falls, etc.) ?*
13. List all related treatments received for this injury in the past.*
Was the previous treatment effective*

YesYes, but temporaryNot effectiveN/A
15. Are you currently seeing any other healthcare professional?*
16. What are the physical duties required of your occupation?*
17. What activities/hobbies do you enjoy?*
18. Please describe your over health at this time.*
Mark any of the following symptoms that apply to you:
Head/Pain

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGrinding sound with neck movementDiagnosed bone spursDisc herniationOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
HEALTH HISTORY PAST AND PRESENT

AllergyAnemiaArthritisAsthmaBack PainBursitisCancerCrampsChest PainDepressionDiabetesEczemaEpilepsyGall BladderGoutHeart DiseaseHeart AttackHigh BPIrregular PeriodsLow BPMigranesMiscarriageMSNervousnessNeuritisPeriod PainRinging in EarsSinus ProblemsStrokeThyroid IssuesUlcersMeaselsMumpsChicken PoxWhooping CoughScarlet FeverDiptheriaSmall PoxPneumoniaRheumatic FeverVenereal DiseaseBladder InfectionsHeadachesTuberculosisPolioGlaucomaHerniaBlood TransfusionHemorrhoidsMitral Valve ProlapseAIDS/HIVInfectious MonoBronchitisHepatitisKidney DiseaseThyroid DiseaseOther
Previous Surgeries (Type, Date, Location)
Medication List (Dosage/Frequency)
Drug Allergies
Use of Alcohol

NeverRarelyModeratelyDaily
Use of Recreational Drugs

NeverRarelyModeratelyDaily
Use of Tobacco

NeverRarelyModeratelyDailyFormer Tobacco User
Family Medical History (Father, Mother, Grandparents, Siblings)
PLACE YOUR CONSENT HERE
Signature*

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Date
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