Clay Cox New Patient Intake Form

Today's Date

MonthDayYear

Patient Name

First NameMiddle NameLast Name

Patient Birth Date

MonthDayYear

AGE

Patient Gender

Marital Status:

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

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?

Have you see other health care professionals for your condition?

Please list other health care professionals seen, and approximate date seen:

Are you currently taking medication?

If yes, please indicate medications below:

Have you experienced any serious accidents or falls within the

If you experienced an accident, what type was it?

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?

Briefly explain:

Been treated for a spine or nerve disorder?

Briefly explain:

Had a fractured bone?

Briefly explain:

Ever been hospitalized (other than for surgery)?

Briefly explain:

Do you currently take any vitamins or minerals?

Briefly explain:

Do you have an allergy to any drugs or medications?

Briefly explain:

Family History

If other, please explain:

Are you pregnant?

Describe you general state of health:

Please indicate the conditions you have had:

Rows	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:

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

Pain or numbness in:

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

Muscle and Joint

Rows	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

Rows	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

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

Respiratory

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

Skin

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

Cardiovascular

Rows	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

Rows	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

Rows	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

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

For Women Only

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

Date of Last:

Rows	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:

Rows	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.

Clay Cox Patient Intake Form

Patient Information