Group Visit Intake

1
Name
First Name
Last Name
2
Myemail
example@example.com
3
Name code 1
4
Name code 2
5
Name
First
Last
6
Date
Date
Year
Month
Day
7
Biological Gender
M
F
8
Birthday* This field is required.Double click the box to enter the date rather than to use the calendar
Month
Day
Year
9
Marital Status
Married
Divorced
Single
Widowed
Separated
10
Time
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
11
Phone Number
12
May we text to this number?
YESNO
13
AddressHome Address
Street Address
Street Address Line 2
City
Please Select
Please Select
PA
DE
NJ
MD
AL
AK
AZ
AR
CA
CO
CT
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MA
MI
MN
MS
MO
MT
NE
NV
NH
NM
NY
NC
ND
OH
OK
OR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
14
Email
example@example.com
15
Do you have any complaints?
YESNO
16
What is your main complaint
No complaint/ maintenance care
head
neck
upper back
lower back
sciatica
hip
shoulder
knee
elbow
TMJ
foot
hand
vertigo
Other
17
Where is the discomfort
right
left
both
Other
18
When did you first notice your symptoms
Date of onset
Year
Month
Day
19
Please describe what you were doing when you felt the pain. Type or speak your answer
Huge
Large
Normal
Small
Ok
Ok
20
What best describes the discomfort?Choose all that apply and click next
sharp
sore
ache
burning
numbness/ tingling
stiffness
weakness
throbbing
tight
Other
21
Does the pain radiate to anywhere else?
YESNO
22
Where does it radiate to?Choose all that apply and click next
head
jaw
neck
upper back
lower back
hip
shoulder
knee
elbow
hand
foot
Other
23
On a scale of 0-10, how would you rate the intensity of the discomfort? 0 = no pain 5 = moderate pain 10 = worst pain
0
1
2
3
4
5
6
7
8
9
10
24
How often does it hurt?
approximately 90-100% of the time
approximately 75% of the time
approximately 50% of the time
approximately 25%.of the time
25
What makes it worse?Choose all that apply and click next
sitting
standing
looking up
looking down
certain positions
laying face up
laying face down
work
exercise
physical activity
walking
running
bending
lifting
stairs
computer use
reaching
twisting
sneezing/laughing
driving
activity
Other
26
What makes it better?Choose all that apply and click next
treatment
rest
heat
standing
sitting
ice
heat
massage/rubbing
creams/gels
medication
stretching
activity
exercise
Other
27
Have you experienced this complaint in the past?
YESNO
28
Comp 1 note
Huge
Large
Normal
Small
Ok
Ok
29
Do you have additional complaints?
YESNO
30
Where is your next complaint?
head
neck
upper back
lower back
sciatica
hip
shoulder
knee
elbow
TMJ
foot
hand
vertigo
Other
31
What best describes the discomfort?Choose all that apply and click next
sharp
sore
ache
burning
numbness/ tingling
stiffness
weakness
throbbing
tight
32
On a scale of 0-10, how would you rate the intensity of the discomfort? 0 = no pain 5 = moderate pain 10 = worst pain
0
1
2
3
4
5
6
7
8
9
10
33
How often does it hurt?
approximately 90-100% of the time
approximately 75% of the time
approximately 50% of the time
approximately 25%.of the time
34
What makes it worse?Choose all that apply and click next
sitting
standing
looking up
looking down
certain positions
laying face up
laying face down
work
exercise
physical activity
walking
running
bending
lifting
stairs
computer use
reaching
twisting
sneezing/laughing
driving
activity
Other
35
What makes it better?Choose all that apply and click next
treatment
rest
heat
standing
sitting
ice
heat
massage/rubbing
creams/gels
medication
stretching
activity
exercise
Other
36
Comp 2 notes
Huge
Large
Normal
Small
Ok
Ok
37
Do you have any additional complaints?
YESNO
38
Please list any other complaints you may have.
39
Ad comp notes
Huge
Large
Normal
Small
Ok
Ok
40
Do you use tobacco?
YESNO
41
Do you drink alcohol?
YESNO
42
Do you use marijuana or street drugs?
YESNO
43
History of infections?
YESNO
44
History of Cancer?
YESNO
45
Taking Anticoagulants?
YESNO
46
Recent spinal surgery or trauma?
YESNO
47
Urinary retention or incontinence?
YESNO
48
Bowel problems?
YESNO
49
Have you ever had any serious injuries, surgeries or been hospitalized?
YESNO
50
Please describe any hospitalizations, surgeries or injuries you have experiencedType or speak your answer
Huge
Large
Normal
Small
Ok
Ok
51
Do you have any allergies?
YESNO
52
Please list any allergiesType or speak your answer
53
Are you on any medications?
YESNO
54
Are you taking medications for any of the following?Check all that apply or select NONE
High Blood Pressure
Heartburn
Diabetes
Seizures
Anti-cholesterol
Pain Medication
Anti-Anxiety/Anti-depressants
Antibiotics
None listed
55
Are you currently taking any of these for your high blood pressure?Scroll down for additional medications.
Privinil
Lisonopril
Vasotec
Enalapril
Altac
Ramipril
Dovian
Valsartan
Cozaar
Lasartan
Norvasc
Amlodipine
Tenormin
Atenolol
Coreg
Carvedilol
Lopressor
Metoprolol
Catapress
Clonidine
Other
56
Are you currently taking any of these for your heartburn?Select other if none apply
Prisolec
Omeprazole
Nexium
Esomeprazole
Prevacid
Lansoprazole
Other
57
Are you currently taking any of these for your diabetes?Select other if none apply
Glucophase
Metformin
Diabeta
Glyburide
Actos
Politazone
Amaryl
Glimepiride
Lantus
Insulin
Glargine
Other
58
Are you currently taking any of these for your seizures?Select other if none apply
Neurontin
Gabapenlin
Lyrica
Pregabalin
Other
59
Are you currently taking any of these for your cholesterol?Select other if none apply
Zocor
SimaS
Lipitor
AtorvaS
Crestor
RosuvaS
Mevacor
LovaS
Pravachol
PravaS
Zetia
Ezetimibe
Tricor
Fenofibrate
Vytorin
Ezetimibe
SimvaS
Other
60
Are you currently taking any of these for your pain?Select other if none apply
Utram
Tramadol
Oxycotin
Oxycodone
Percocet
Vicodin
Tylenol 3
Darvocet
Neurontin
Gabapenlin
Other
61
Are you currently taking any of these for your anxiety or depression?Select other if none apply, scroll for more options
Xanax
Alprazolam
Ativan
Lorazepam
Valium
Diazepam
Klonopin
Clonazepam
Zoloft
Sertaline
Lexapro
Escitalopram
Prozac
Fuoxetine
Cymbalta
Duloxeline
Desyrel
Trazadone
Celexa
Citalopram
Effexort
Venlafaxine
Elavil
Amitriptylline
Other
62
Are you currently taking any of these antibiotics?Select other if none apply, scroll for more options
Amoxil
Amoxicillin
Augumentin
Amoxicillin + Clavulanate
Keflex
Cephalexin
Omnicef
Cefdinir
Zithromax
Cizithromycin
Vibramycin
Doxycycline
Cipro
Ciproflaxcin
Levaquin
Levofloxacin
Septra
Sulfamethotazole + trimethoprim
Other
63
Please list which other medications you are on and why
Huge
Large
Normal
Small
Ok
Ok
64
Are you currently under any other medical care?
YESNO
65
Who do you see?
Primary Care
Physical Therapist
Orthopedic
Neurologist
Massage Therapist
Emergency Room/ Urgent Care
Other
66
Please list any other health conditions, symptoms or concernsType or speak your answer
67
Privacy Procedure* This field is required.
Should be Empty: