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New Injury Patient Intake — Edinger Urgent Care + Occupational Medicine
Complete this intake form with your injury details, symptoms, and medical history.
Check-in screening
Do you currently have a fever, cough, or other symptoms of illness?
*
Yes
No
Patient Information
Last name
*
First name
*
Middle initial
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home phone
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
*
Female
Male
Prefer not to say
Social Security number
Email
example@example.com
Preferred language
*
English
Spanish
Other
Marital status
Please Select
Single
Married
Domestic partnership
Divorced
Separated
Widowed
Other
Race/ethnicity
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Two or more races
Other
Prefer not to say
Injury Information
Employer / company name
Job title
Date of injury
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of injury
Hour Minutes
AM
PM
AM/PM Option
Date reported to employer
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor name
Supervisor phone
Please enter a valid phone number.
Format: (000) 000-0000.
Body part(s) injured
*
Head
Face
Neck
Shoulder
Upper arm
Elbow
Forearm
Wrist
Hand
Finger(s)
Upper back
Mid back
Lower back
Chest
Abdomen
Hip
Thigh
Knee
Lower leg
Ankle
Foot
Toe(s)
Multiple areas
Other
How did the injury happen?
*
Have you already been seen or treated anywhere else for this injury?
*
Yes
No
If yes — where / by whom?
Before this injury, have you ever had pain, an injury, or treatment involving this same body area?
*
Yes
No
If yes — when / what happened?
Did anyone see the injury happen?
*
Yes
No
Witness name
Workers' comp claim number (if known)
Emergency Contact & Driver's License
Emergency contact name
*
First Name
Last Name
Relationship
*
Emergency contact phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Driver's license number
License state
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
CDL/CLP class (if any)
Pain & Symptom Assessment
Which body areas are affected?
*
Head
Neck
Shoulder
Arm / Elbow
Wrist / Hand
Chest
Upper back
Lower back
Hip
Leg / Knee
Ankle / Foot
Other
Which side?
Left
Right
Middle
What type of pain is it?
Aching / dull
Sharp / stabbing
Burning
Numbness / tingling
Throbbing
Where is the pain?
Pain RIGHT NOW
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
WORST pain in the past 3 days
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
BEST pain in the past 3 days
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
My pain is:
*
Constant
Comes and goes
Only with activity
What makes it worse?
What makes it better?
Since the injury, my symptoms are:
*
Getting worse
About the same
Improving
Brief Medical History
Check any that apply to you
Diabetes
High blood pressure
Heart disease
Cancer
Arthritis
Osteoporosis
Kidney or liver disease
Prior surgery
None of these
Current medications (write None if none)
Allergies — medications / latex / environmental (write None if none)
Do you use tobacco or nicotine?
*
Yes
No
Are you, or could you be, pregnant?
Yes
No
N/A
Which hand do you write with?
Right
Left
Certification
I certify that the information on this form is true and complete to the best of my knowledge.
E-signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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