Patient Summary - Domestic / US Patients
Thank you for reaching out to Healing Hands of Nebraska.  To make this process easier, we've included the actual form in this email - please feel free to fill it out directly here in your email.  Alternatively, if you'd prefer, you can click on the "FILL OUT IN GOOGLE FORMS" at the top.  

In order to schedule an appointment with Dr. Aguila, he requests that each patient complete this form.

If your symptoms are not pain-related, please give as much detail as you can regarding the type of symptoms you have, when, how often, how severe, and how it has been treated in the past.

Please also email us (info@doctoraguila.com) any supporting documentation (MRI / CT / X-ray reports, etc) that you think might be helpful.

Finally, please click "Review and Submit" at the end of this form to send the information back to us, and we will get in touch with you shortly.

Thank you.

The Healing Hands of Nebraska Team
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Email *
Surname / Last Name *
First Name *
Middle Name
Date of Birth *
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Telephone Number *
Primary Language *
I understand that Healing Hands of Nebraska does not have any insurance contracts and does not participate in any health insurance programs.  I also understand that Healing Hands of Nebraska will not perform any billing for out-of-network benefits, and that is the responsibility of the patient.  I also agree that I will be fully responsible for the cost of any services provided by Healing Hands of Nebraska. *
I am interested in using the following for the cost of my care: *
State (USA) / Province (Canada) / Other (outside USA / Canada) *
Town / City *
For which of the following problems are you contacting Dr. Aguila? (CHECK ALL THAT APPLY) *
Required
Which of the following medical conditions do you have? *
Required
Which of the following medicines are you taking? (CHECK ALL THAT APPLY) *
Required
How did you find Dr. Aguila? *
Who referred you to us? *
Body part experiencing symptoms / pain (CHECK ALL THAT APPLY) *
Required
What SIDE of the body is in pain? *
What TYPE of symptoms are you experiencing? (CHECK ALL THAT APPLY) *
It is very important that you provide as much detail as possible regarding the type of symptoms that you first experienced (i.e. pain, weakness, sensory changes like numbness, tingling, etc.)
Required
Has your current pain/problem ever caused you to consider committing suicide / taking your own life? *
Have you ever considered harming yourself? *
Who else have you seen about these symptoms? (CHECK ALL THAT APPLY) *
Required
Which of the following tests have you had for these symptoms? (CHECK ALL THAT APPLY) *
Required
Patient Summary *
Describe how your pain felt when it first started and how it progressed or changed over time *IN CHRONOLOGICAL ORDER*. As you write your summary, please include brief descriptions of anything that made your problem better or worse– please be detailed when describing the changes that resulted. 

Please end your story with a current summary of all your various pain complaints and specifically where all pain is located.

This symptom summary should reflect what you are currently experiencing on a day-to-day basis. Please be as clear and concise as possible.

Please answer the questions below and provide a detailed patient summary of your condition from the very start of the problem up to the present time.
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Healing Hands of Nebraska, PC.