Patient Name
First Name
Last Name
Phone
Gender
MaleFemale
Date
Weight
Age
Date Of Birth
Marital Status
MarriedSingleDivorcedSeparated
Phone Number
Cell Phone
Work Phone Number
Email
Street Address
Address Line 2
Postal / Zip Code
P.O. Box Address if applicable
Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe
State
Select State
City
Select City
Occupation and Employer
Insurance Provider
Who may we thank for referring you? How did you hear about us?
Relationship
What is the primary reason for this visit?
This condition is due to?
This condition is due to?Automobile accidentWork injurySports/ exercise injuryIllnessNot sureOther
Date of injury/ illness?
When did your symptoms begin?
SuddenlyGraduallyOther
How long do symptoms last?
In the morningIn the eveningAll dayOccasionallyIntermittentlyConstantlyDuring sleepUpon wakingOther
if Other was checked, specify here:
What initiates your symptoms?
What makes them worse?
What makes them better?
Have you received treatment for this complaint?
YesNoSelf treatment only
If Yes, what was done? Did it help?
What has prevented you from getting well in the past?
Do you have specific questions you would like to discuss in this visit?
Check all which have occurred in any of your blood relatives:
Check all which have occurred in any of your blood relatives:AlcoholismAllergyBleed easilyCancerDeathDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessObesityStroke
List any other family ailments not listed above:
Other illness(es) which have occurred in any of your blood relatives:
How would you describe your health as a child?
Check illnesses or conditions you have or had in the past: Check illnesses or conditions you have or had in the past:AIDs/HIVAlcoholismAllergiesAntibiotic useAsthmaBleed easilyCancerChicken PoxDiabetesEpilepsyGallbladder ProblemsGlaucomaHeart DiseaseHepatitisHigh Blood PressureHigh FeversJaundiceKidney ProblemsMeaslesMeningitisMental DisordersMultiple SclerosisMumpsPacemakerPneumoniaPolioRheumatic FeverScarlet FeverStrokeThyroid DisordersTuberculosisTyphoid FeverUlcersVascular DiseaseVenereal Disease
List any other illnesses or conditions you have or had in the past that were not listed above:
List illness(es) NOT requiring surgery for which you have been hospitalized:
List illness(es) requiring surgery (including date)
List any other serious injury, broken hones, scars, etc.:
Is there anything you are unwilling to change in order to get well?
Have you ever taken any antibiotics? For what? How long?
List of prescription and over the counter medications you are currently taking and reason:
List allergies or sensitivity to any medicines or other substances:
What do you feel is a resonable time frame in which to reach satisfactory resolution of your primary complaint?
Name of primary doctor or physician:
Address:
Phone:
List RESULTS and DATE of last medical tests:
In the process of getting well, what % of the responsibility do you think is your own/ doctors?
Comments: (anything else you would like to tell us or talk about in your visit with us today?)
By TYPING MY NAME IN THE FIELD BELOW, I am stating that all information on this form is correct and complete to the best of my abilities. I understand I must also sign below.
