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Health Intake Form
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
Your answer
Height (e.g. 6'1")
Your answer
Weight (lb)
Your answer
Occupation
*
Your answer
How were you referred or hear about us?
Your answer
Reason for todays visit:
New Injury
Old Injury
Chronic Pain
Wellness Visit
Check off any of the following symptoms you have experienced in the past 6 months:
*
Low back pain
Dizziness
Neck pain
Tension headaches
Tired/Fatigued
Wrist/Hand pain
Digestive problems
Elbow pain
Shoulder pain
Hip pain
Knee pain
Ankle/foot
Ringing in ears
Weight problems
Tension across top of shoulders
Pain between shoulder blades
Numbness or tingling in arms
Numbness or tingling in legs
Difficulty sleeping
Allergies
Nervousness
Required
Which of the above is worse?
*
Your answer
On a scale of 1 to 10, please rate the the pain level of your main complaint:
*
Discomfort
1
2
3
4
5
6
7
8
9
10
Intense
How long have you had it?
Your answer
Would you like to get rid of the problem?
Yes
No
Clear selection
What medications are you taking?
Your answer
Is there anything else that you want to ask the Doctor?
Your answer
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