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Patient Intake
Patient Intake
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Step
1
of 3
Patient name
*
DOB
*
CONDITIONS
Arthritis
Asthma
Back Trouble
Bursitis
Cancer
Constipation
Diabetes
Disc Problem
Emphysema
Epilepsy
Headaches
Heart Trouble
High Blood Pressure
Insomnia
Kidney Trouble
Liver Trouble
Migraine
Nervousness
Neuritis
Neuralgia
Pinched Nerve
Scoliosis
Sinus Trouble
Stomach Trouble
Other
Next
Primary Phone
*
E-mail:
*
City:
*
State:
*
Zip:
*
Alternative Phone:
Age:
*
Birth Date:
*
Race:
Martial ( M S W D ):
*
Occupation:
*
Employer:
*
Employer's Address:
*
Office Phone:
*
How many children?
Address:
How were you referred to our office
*
Please check any of and all insurance coverage that may be applicable in this case
Major Medical
Worker's Compensation
Medicaid
Medicare
Auto Accident
Medical Savings Account & Flex Plans
Other/Non Insured/Cash
Name of Secondary Insurance Company (if any)
AUTHORIZATION AND RELEASE:
I authorize payment of insurance benefits directly to the provider or clinic. I authorize my provider to release all information's necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that i am responsible at all cost of medical care, regardless of insurance coverage. I also understand that if i suspend or terminate the schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable, You understand and have read this connect .
Next
HEALTH ISSUES AND CONDITIONS (Continued)
Dizziness
Shoulder/Neck/Arm pain
Numbness in fingers
High Blood pressure
Difficulty Urinating
Weakness in Extremities
Breathing Problems
Fatigue
Lights Bother Eyes
Ears Ring
Broken Bones/Fractures
Rheumatoid Arthritis
Excessive Bleeding
Osteoarthritis
Pacemaker
Stroke
Ruptures
Eating Disorder
Drug Addiction
Gall Bladder Problems
Ulcers
Frequent Colds
Fever
Sinus Problems
Diabetes
Indigestion Problems
Joint Pain/Swelling
Menstrual Difficulties
Weight Loss/Gain
Depression
Loss of Memory
Buzzing in Ears
Circulation Problems
Seizures/Epilepsy
Low Blood Pressure
Osteoporosis
Heart Disease
Cancer
Coughing Blood
Alcoholism
Hiv Positive
Depression
SOCIAL HISTORY
Vigorous Exercise
OFTEN
SOMETIMES
NEVER
Moderate Exercise
OFTEN
SOMETIMES
NEVER
Alcohol Use
OFTEN
SOMETIMES
NEVER
Drug Use
OFTEN
SOMETIMES
NEVER
Tobacco Use
OFTEN
SOMETIMES
NEVER
Caffeine:
OFTEN
SOMETIMES
NEVER
High Stress Activity
OFTEN
SOMETIMES
NEVER
Family Pressures:
OFTEN
SOMETIMES
NEVER
Financial Pressures:
OFTEN
SOMETIMES
NEVER
Other Mental Stress:
OFTEN
SOMETIMES
NEVER
Describe other mental stress:
HISTORY OF PRESENT AND PAST ILLNES
Chief Complaint: Purpose of this appointment:
WHEN DID SYMPTOMS APPEAR?
Are they getting worse?
Yes
No
IF VISIT IS DUE TO ACCIDENT: Date accident happened (if applicable)
Is due to:
Auto
Work
Other
Have you ever had the same or similar condition?
Yes
No
if yes? when and describe
Days lost from work
Date of last physical examination:
Do you have history of stroke or hypertension
Have you had any major illnesses, injures, falls, auto accidents or surgeries? Women please include information about childbirth include dates
Have you been treated for any health condition by a physician in the last year
Yes
No
If yes describe:
What medicine or drugs are you taking?
Do you have any allergies to any medications?
Yes
No
Describe about medicine and allergies
Do you have any allergies?
Yes
No
Describe about your allergies
Do you have any Congenital Condition?
Yes
No
Describe about Congenital Condition
Women: are you pregnant?
Date of last menstrual period:
HEALTH ISSUES AND CONDITIONS
Have you had or you now have any of the following symptoms/conditions?
Please indicate with the letter N for now and P if you had this conditions/symptoms
Headaches
Neck Pain
Stiff Neck
Sleeping Problems
Back Pain
Nervousness
Tension
Irritability
Chest Pain/Tightness
Loss of Balance
Fainting
Loss of Smell
Loss of Taste
Unusual Bowel Patterns
Feet Cold
Hands Cold
Arthritis
Muscle Spasms
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