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

Format: 000-000-0000.

Work Phone Number

Format: 000-000-0000.

E-mail

example@example.com

Social Security #

Driver's License #

Marital Status

Spouse's Name

Employer & Occupation

Employer Address

How did you hear about us?

Insurance Name

ID / Member Number

Group Number

Insured's Name

Relationship to Patient

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

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:

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

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

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

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

HEALTH HISTORY PAST AND PRESENT

Previous Surgeries (Type, Date, Location)

Medication List (Dosage/Frequency)

Drug Allergies

Use of Alcohol

Use of Recreational Drugs

Use of Tobacco

Family Medical History (Father, Mother, Grandparents, Siblings)

PLACE YOUR CONSENT HERE

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date