Visit Register
Please obtain Patient Identifier Number (PIN) from us before applying. For privacy and security reason, do not fill in your name and email address here. Instead, only use your patient number in this form and other forms as well.
Sign in to Google to save your progress. Learn more
PIN (Patient Identifier Number) *
Enter numbers only. Do not use other patient's PIN
New visit or longer than 3 years since prior visit? *
If yes, you need to fill out Physicals. If you did it 3 years ago, we need a new update to your Physicals. Choose No if you visited us recently (established patient) and make sure to fill out your post- treatment feeling in the Current Medical History field.
Chief Complaint (CC) for This Visit *
The main reason (The main symptom you concern or want treatment the most) for current visit.
Since when *
Since when Chief Complaint happened. Approximated date is OK if you don't remember exactly
MM
/
DD
/
YYYY
Scale of pain intensity (skip if no pain) *
minimal (slight) pain
maximal (intolerable) pain
Daily Pain Hours
Number only! Skip this question if no pain. How many hours are there in a day that you feel the pain. If painful when moving but no pain when not moving, put in 24 hours less your sleep hours.
How/when Chief Complaint has happened, proceeded and treated?
Any unusual or suspicious event/incident happened prior to Chief Complaint
Current Medical History
1. For established patient, please describe the result of your recent treatment, including the feelings, changes and timing, no matter seemingly good or bad, relevant or irrelevant. 2. For new patient, describe all visited medical doctors, exams and test results, diagnoses, treatments and results:All details toward Chief Complaints, the more detailed the better.
Past Sickness History
List any past medical treatments, including all natural therapies.
Other notes
List anything you like to add.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy