Medical Health Insurance Intake

Patient Intake Form
HISTORY AND PHYSICAL INTAKE FORM

PATIENT INFORMATION.*

	Please fill up with the correct information.
Patient Name
Date Of Birth
Address
Phone #
Email

PLEASE TELL US HOW YOU WERE REFERRED TO US?

	Please fill the REFERRAL SOURCE information below.
Friend (Name?)
Facebook / Instagram
Groupon
TikTok
Other Social media
Print Add
Doctor (Name?)
Other?

PAST MEDICAL HISTORY.*

	Yes	Description
Diabetes
Arthritis
Cancer
Erectile Dysfunction
Chronic Pain (Where?)
Fibromyalgia
Interstitial Cystitis
Stress Urinary Incontinence (Female)
Polyneuropathy
Depression
Anxiety
Parkinsons
Multiple Sclerosis
Other
None

FAMILY & FRIEND HISTORY.

	Yes/No
Does any of your friends have any of the above?

- Pls tell them to call us and schedule evaluation and give your reference to us while making appointment.
- Please list friends or family needing help for above and phone numbers.
(Free Shock Wave treatment when they get treated by us from your referral).
SURGICAL HISTORY.

Please write about your surgical history in the box below.

->
REVIEW OF SYSTEM.

Please tell us any other symptoms we should know of.

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ALLERGIES.*

	Yes	Description
No Known Drug Allergies
IV Dye
Iodine
Seafood/Shellfish
Latex
Adhesive Tape
NSAIDS
Penicillin
Local Anesthetic
Other Allergy

CURRENT MEDICATIONS & SUPPLEMENTS.

	Name	Dosage
1
2
3
4
5
6
7
8

Name*

First NameLast Name
Date

MonthDayYear
Date
Signature

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