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New Patient Information
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Today's Date
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MM
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DD
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YYYY
Personal Information
Please accurately fill out the information below.
First Name
*
Your answer
Last Name
*
Your answer
Sex
*
Female
Male
Prefer not to specify
Date of Birth
*
MM
/
DD
/
YYYY
Email Address
*
Your answer
Phone Number
Your answer
Address
Your answer
Referring Physician & Phone Number
*
Your answer
Insurance
Please provide valid health insurance.
Primary Insurance
*
Your answer
Policy Number
*
Your answer
Policy Holder Name & DOB
*
Your answer
Insurance Phone Number
*
Your answer
History
Please provide information regarding your health history.
How often do you exercise?
Less than 30 minutes
30-60 minutes
More than 60 minutes
1-2 days a week
3-4 days a week
5 or more days a week
Less than 30 minutes
30-60 minutes
More than 60 minutes
1-2 days a week
3-4 days a week
5 or more days a week
Clear selection
When was the last time you smoked?
Within the last week
Within the last month
Within the last 6 months
Within the last year
Within the last 5 years
Longer than 5 years ago
I have never smoked
Clear selection
Are you pregnant?
Yes
No
Maybe
Clear selection
Do you have a Pacemaker?
Yes
No
Clear selection
What medications are you currently taking?
Your answer
Do you have previous diagnosis?
Yes
No
Other:
Clear selection
If so what was the diagnosis?
Your answer
Have you ever had spinal surgery?
Yes
No
Clear selection
Have you recently been in an auto accident?
Yes
No
Clear selection
Current Complaints
Please provide information on your current physical condition.
What is your major concern today?
*
Your answer
When did you start noticing this problem?
MM
/
DD
/
YYYY
Probable cause for this pain?
Your answer
How would you rate your amount of pain?
*
Barely noticeable
1
2
3
4
5
6
7
8
9
10
Intolerable; needing medical assistance ASAP
What is the nature of your pain? Please select all that apply.
Work Related
Recreational
Chronic / Recurrent
Lifting or Carrying objects
Fall
Post Surgery
Other:
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