Online Doctor Appointment Form

Patients Personal details

Fill the form below. We will contact you to confirm your appointment.
Full Name*
Phone Number*

Area CodePhone Number
Reason for appointment:*
Primary Language:
May we leave a message?*

YesNo
Date of Birth*

DayMonthYear
Gender
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail Address*
Have you previously attended our facility*

YesNo
If Yes, state on which condition and when?
What specific problem brings you to our office today?
How long ago did this problem first start?
Did your pain or problem:

Begin all of a suddenGradually develop over timeOther
How would you rate your pain on a scale from 1-10?
0 being no pain, 10 being the worst pain possible)
How would you describe your pain?

no painsharpdullachingburningradiatingitchingstabbingOther
Since the time your pain or problem began, has it:

Stayed the sameBecome worseImprovedOther
What makes your pain or problem feel worse?

walkingstandingdaily activitiesresingdress shoeshigh heelsflat shoesany closed toe shoerunningOther
What makes your pain or problem feel better?
What treatments have you had for this problem?
How has this problem affected your lifestyle or ability to work?
Was this problem caused by an injury?
If yes, was it work related?
Is there a family member or other person you would like for us to share your medical information?
If yes, please provide name:
Do you have a legal guardian or healthcare power of attorney?

YesNo
Emergency Contact Name:
Emergency Contact Phone number:
Relationship to Emergency Contact:
Primary Care Doctor:
Who referred you to us?
Pharmacy Name and Location:
Employer:
Occupation:
How much are you on your feet at work?
Do others depend upon you for their care?
Exercise:

NeverRareOccasionalWeeklySeveral Times a WeekDaily
Types of exercise:
Do you have a family history of:

DiabetesCancerHeart DiseaseHigh Blood PressureStrokeCoronary Artery DiseaseThyroid DiseaseRheumatoid ArthritisOther
Allergies:

none knownAnesthesiatapelatexshellfishiodineMedicationsOther
Have you ever had any of the following:
Acid Reflux:

YesNo
Anemia:

YesNo
Arthritis:

YesNo
Asthma:

YesNo
Back Trouble:

YesNo
Bladder Infections:

YesNo
Abnormal Bleeding:

YesNo
Blood Clots:

YesNo
Blood Transfusion:

YesNo
Bronchitis/Emphysema:

YesNo
Cancer:

YesNo
Diabetes:

YesNo
Fibromyalgia:

YesNo
Gout:

YesNo
Heart Attack:

YesNo
Heart Disease/Failure

YesNo
Hepatitis:

YesNo
HIV+/AIDS

YesNo
High Blood Pressure

YesNo
Kidney Disease:

YesNo
Liver Disease

YesNo
Low Blood Pressure:

YesNo
Migraine Headaches

YesNo
Mitral Valve Prolapse:

YesNo
Neuropathy:

YesNo
Open Sores:

YesNo
Pneumonia:

YesNo
Polio:

YesNo
Rheumatic Fever

YesNo
Sickle Cell Disease:

YesNo
Skin Disorder:

YesNo
Sleep Apnea:

YesNo
Stomach Ulcers:

YesNo
Stroke:

YesNo
Thyroid Disease:

YesNo
Tuberculosis:

YesNo
Pharmacy phone number:
Primary Insurance Company
Insurance ID#
Secondary Insurance Company
Secondary Insurance ID#
Please list all medications you are currently taking (include prescriptions, over-the-counter medications and herbal supplements):
Please list all prior surgeries:
Type of surgery and date.
Please list all prior hospitalizations (other than for surgery):
Reason for hospitalization and date.
Marital Status:

SingleMarriedPartneredSeparatedDivorcedWidowed
Use of Alcohol:

NeverNo Longer UseHistory of Alcohol AbuseCurrent UseOther
Use of Tobacco

NeverQuitSmokeOther
Use of Recreational Drugs

NeverQuitCurrent UseOther
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Signature:

Clear
Should be Empty:

Patients Personal details