New Patient In-Take Form

Choose Our Location Closest To You:*
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

FemaleMale
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security
Your Occupation
Retired?

YesNo
Spouse's Name

First NameLast Name
How did you hear about us?*

REVIEW OF SYMPTOMS
Please check all that apply*

Foot PainHand PainLow Back PainNeck PainFoot NumbnessHand NumbnessDiabetesHigh CholesterolHigh Blood PressurePacemaker/DefibrillatorHerniated DiscBulging DiscSpinal StenosisDegenerative DiscVascular ProblemsLeg PainPlantar FasciitisMorton's NeuromaCancerChemotherapyArthritis in HandsArthritis in FeetSciaticaPinched NervePoor CirculationJoint ReplacementFoot SurgeryPoor Wound HealingExcessive Thirst or UrinationImplanted Cord/Bladder Stimulator
PRESENT HEALTH CONDITION
In order of importance, list the health problems you are most interested in getting corrected: (click the + button to add more)
List approximately how long you have noticed these problems: (click the + button to add more)
Is there a certain time of day any of these problems are better or worse?
Check the things you have used for these problems:

GabapentinNeurontinLyricaCymbaltaPhysical TherapyPain MedicationsAleveTylenolIbuprofenMotrinChiropracticMassage TherapyInjectionsCreamsOther
Is your balance/walking ability affected?

YesNo
If yes, please describe:
What do you think is causing your problem?
List all of the doctors you have seen for these problems and treatment you received: (click the + button to add more)
Have your symptoms:*

ImprovedWorsenedStayed the same
List anything that makes your condition worse: (click the + button to add more)
List anything that makes your condition better: (click the + button to add more)
How would you describe the symptoms? Please check all that apply*

Aching PainStabbing PainSharp PainTirednessNumbnessTinglingPins & Needles PainHeavy FeelingHot SensationThrobbing PainDead FeelingCold Hands/FeetCrampingSwellingBurningElectric ShocksNoneOther
Is this condition interfering with any of the following?*

SleepWorkWalkingStandingDaily ActivitiesRecreational ActivitiesNoneOther
List all allergies/sensitivities to medication, food and other items here: (click the + button to add more)
List all prescription drugs you are currently taking and dosage of each: (click the + button to add more)
List all nutritional supplements (vitamins, herbs, homeopathics, etc) you are currently taking and dosage of each: (click the + button to add more)

SOCIAL HISTORY
Do you smoke?

YesNo
If yes, how many cigarettes daily?
Do you drink?

YesNo
If yes, how many drinks per week?
Do you exercise regularly?

YesNo
If yes, please describe type & how often:
CURRENT PAIN LEVELS
With 1 being "No Pain" and 10 being the "Worst Pain Possible"; How would you rate your pain in the last week
With 1 being "No Pain" and 10 being the "Worst Pain Possible"; If you had to accept some level of pain after completion of treatment, what would be an acceptable level?

REVIEW OF SYMPTOMS

PRESENT HEALTH CONDITION

SOCIAL HISTORY

CURRENT PAIN LEVELS

PATIENT QUALITY OF LIFE SURVEY