Health History

Your Vehicle Insurance Info

MedPay is an optional addition to the regular coverage on your policy. It covers your medical expenses and does not affect your deducible nor raise your premium.
Do you have MedPay (Medical Payments) on your policy?*

YesNo
Your car insurance company
How much?
ex: $1,000, $5,000, $10,000
Adjuster's Name

First NameLast Name
Claim Number
Was anyone ticketed?*

NoYes, themYes, me

What can we help you with?

Details on your current condition(s). This online form allows you to submit up to 4 conditions. Please focus on one at a time.
Why are you seeking care?*
You will have the opportunity to enter additional reasons later
Why are you seeking care?*
You will have the opportunity to enter additional reasons later
Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*

YesNo
Please describe*

Is anything else bothering you?*

NoYes
Additional Problem*
You will have the opportunity to enter additional reasons later
Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*

YesNo
Please describe*

Is anything else bothering you?*

NoYes
Additional Problem*
You will have the opportunity to enter additional reasons later
Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*

YesNo
Please describe*

Is anything else bothering you?*

NoYes
Additional Problem*
You will have the opportunity to enter additional reasons later
Does the pain radiate? (travel from one area to another - i.e. low back pain that also goes down the legs)*

YesNo
Please describe*

Please list any activities you have difficulty with or are unable to perform.
Dressing, grooming, sitting, lifting, yard work, house chores, etc.

Long-term Goals*
If you are seeking care due to pain or a specific problem then the short-term goal is elimination of the issue(s). What are your overall plans for your health?
Additional comments
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New Patient Health History