Clay Cox New Patient Intake Form

Clay Cox Patient Intake Form
Today's Date*

MonthDayYear
Patient Information
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
AGE*
Patient Gender*
Marital Status:

SingleMarriedDivorcedWidowedSeparatedDomestic Partner
Number of Children
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient E-Mail*
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Status

EmployedUnemployedRetiredDisabled fom work
Employer
Occupation
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Phone

Area CodePhone Number
Current Job Description
Past Jobs Held
Name of Spouse
Spouse's Occupation
Spouse's Employer
Phone Number
In Case of Emergency Please Contact
Emergency Contact Phone
How did you hear about Clay Cox?
Please list complaints and the date the condition started, starting with your major complaint.
Complaint 1*
Date started
Complaint 2
Date started
Complaint 3
Date started
Is You Condition Getting Worse?

YesNoConstantIt Comes and GoesNot Sure
Have you see other health care professionals for your condition?

YesNo
Please list other health care professionals seen, and approximate date seen:
Are you currently taking medication?

YesNo
If yes, please indicate medications below:
Have you experienced any serious accidents or falls within the

Past yearPast 5 yearsOver 5 yearsNever
If you experienced an accident, what type was it?

AutoWorkHomeLeisureSportsOther
Briefly explain the accident:
List surgical operations you have had and the approximate date:
Operation 1
Date
Operation 2
Date
Operation 3
Date
Have you ever:
Been knocked unconscious?

YesNo
Briefly explain:
Been treated for a spine or nerve disorder?

YesNo
Briefly explain:
Had a fractured bone?

YesNo
Briefly explain:
Ever been hospitalized (other than for surgery)?

YesNo
Briefly explain:
Do you currently take any vitamins or minerals?

YesNo
Briefly explain:
Do you have an allergy to any drugs or medications?

YesNo
Briefly explain:
Family History

Heart DiseaseDiabetesAnemiaTBStrokeKidney DiseaseCancerHIVOther:
If other, please explain:
Are you pregnant?

YesNo
Describe you general state of health:

Please indicate the conditions you have had:

	Click to edit
Alcohol Abuse
Anemia
Appendicitis
Arthritis
Blood Transfusion
Cancer
Chorea
Cold sores
Diabetes
Diphtheria
Eczema
Emphysema
Epilepsy
Fever blisters
Goiter
Gout
Heart disease
Influenza
Lumbago
Malaria
Measles
Miscarriage
Multiple sclerosis
Osteoporosis
Pleurisy
Pneumonia
Polio
Rheumatic fever
Scarlet fever
Stroke
Tuberculosis
Typhoid fever
Ulcers
Venereal disease
Whooping cough

Check the following conditions you have had PRIOR to your current injury, as well as the symptoms you are CURRENTLY experiencing:

	Prior	Current
Allergy
Chills
Convulsions
Dizziness
Fainting
Fatigue
Fever
Headache
Loss of Sleep
Nervousness/depression
Neuralgia
Numbness
Sweats
Tremors

Pain or numbness in:

	Prior	Current
Shoulders
Arms
Elbows
Hands
Hips
Legs
Knees
Feet
Painful tail bone

Muscle and Joint

	Prior	Current
Arthritis
Bursitis
Foot trouble
Hernia
Low back pain
Neck pain or Stiffness
Pain between shoulders
Poor Posture
Sciatica
Spinal curvature
Swollen joints

Eyes, Ears, Nose, and Throat

	Prior	Current
Asthma
Colds
Crossed eyes
Deafness
Dental decay
Earache
Ear discharge
Enlarged glands
Enlarged thyroid
Eye pain
Failing vision
Far sightedness
Gum trouble
Hay fever
Hoarseness
Nasal obstruction
Near sightedness
Nosebleeds
Sinus infection
Sore throat
Tonsillitis

Endocrine

	Prior	Current
Constant thirst
Almost always cold
Too warm most of the time
Very sluggish or tired
Jumpy/nervous

Respiratory

	Prior	Current
Chest pain
Chronic cough
Difficult breathing
Spitting up blood
Spitting up phlegm
Wheezing

Skin

	Prior	Current
Boils
Bruise easily
Dryness
Hives or allergy
Itching
Skin eruptions (rash)
Varicose veins

Cardiovascular

	Prior	Current
Hardening of arteries
High blood pressure
Low blood pressure
Pain over heart
Poor circulation
Rapid heart beat
Slow heart beat
Swelling of ankles

Gastrointestinal

	Prior	Current
Belching or gas
Colitis
Colon trouble
Constipation
Diarrhea
Difficult digestion
Distension of abdomen
Excessive hunger
Gall bladder trouble
Hemorrhoids
Intestinal worms
Jaundice
Liver trouble
Nausea
Pain over stomach
Poor appetite
Vomiting
Vomiting of blood

Genitourinary

	Prior	Current
Bed wetting
Blood in urine
Frequent urination
Inability to control bladder
Kidney infection or Stones
Painful urination
Prostate trouble
Puss in urine

Psychological

	Prior	Current
Often feel depressed
Have irrational fears
Feel upset or angry
Feel things often go wrong
Cry easily

For Women Only

	Prior	Current
Congested breasts
Cramps or backache
Excessive menstrual flow
Hot flashes
Irregular cycle
Menopausal symptoms
Painful menstruation
Vaginal discharge

Date of Last:

	Less than 6 months	6-18 months	More than 18 months	Never
Physical Exam
Spinal Exam
Blood Test
CT Scan
MRI
Chest X-ray
Spinal X-ray
Dental X-ray
Urine Test

Habits:

	Heavy	Moderate	Light	None
Alcohol
Coffee
Tobacco
Drugs
Television
Exercise
Sleep
Appetite

I understand that it is my responsibility to keep the appointments that I make. If I am unable for any reason to keep that appointment, I will notify the office of Clay Cox at least 24 hours in advance of that appointment. If I am not able to keep these agreements, I understand that I am responsible for payment for the session missed.*

By checking this box and submitting this form to Clay Cox you are agreeing to the terms above.
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Clay Cox Patient Intake Form

Patient Information