Intake Form

Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth?
Last 4 digits of Social Security Number?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Mobile/Texting number
Please enter a valid phone number.
Email
example@example.com
Referring Physician Name and Phone Number?
Primary Care Physician Name and Phone Number?
Emergency Contact Name, Relationship to The Patient and Phone Number?
Pharmacy Name, Address, Phone Number, and Fax Number?
Primary Insurance Name, Address, Phone #, ID #, Group #
Secondary Insurance Name, Address, Phone #, ID #, Group #
Why would you like to be seen today?
Is this condition work or accident related? If so, Date of Injury?
Past Injuries?

Motor Vehicle AccidentSports injuryDisabilityWorker's Compensation Injury
Height?
Weight?
Right or Left Handed?
Past/Present Medical History: Check only the items that apply.

Heart ProblemsHigh Blood PressurePacemakerHeart StentChest PainsStrokeMigraine HeadachesSeizure DisorderLung ProblemsAsthmaCOPDPneumoniaTuberculosisWearing Oxygen at HomeReaction to AnesthesiaCirrhosisLiver ProblemsHepatitisStomach/Intestine ProblemsUlcersArthritisRheumatoid ArthritisDiabetes or High Blood SugarBleeding DisorderHistory of Blood ClotsAIDSMRSAPregnant nowKidney StonesKidney ProblemsDialysisPost COVIDSick NowNot able to walk 2 flights of stairsNot able to go for reasonably long walksADHDHormone DeficiencySee a Psychiatrist/PsychologistOther
Have you ever been diagnosed with a condition? If so, list it here.
Past Surgical History: List Surgeries you have had and date.
Past Family History: Do Medical Problems Run in your Family? List Family Member and Condition
List Allergies and Medication Allergies with the reactions and sensitivities.
Current Medications you are taking. List name, dosage, and frequency.
Have you had any of the following conservative therapies? Check all that apply.

Physical TherapyPool TherapyChiropractic TreatmentAcupunctureEpidural Steroid InjectionsTrigger Point InjectionsOther
Would you like to tell the doctor for Lively Virtual Care Organization any additional information about your health?
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