New Patient Intake- Elevate Human Potential
Email address *
Name (Last, First, Middle) *
Your answer
Date of Birth (month/date/year) *
Your answer
Gender *
Ethnicity *
Race *
Preferred Language *
Your answer
Sexual Orientation *
Address *
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City *
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State *
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Zip Code *
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Phone Number *
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Emergency Contact Name *
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Emergency Contact Phone *
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Preferred communication *
How did you hear about us? *
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Personal Medical History- Please mark all that apply *
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Personal Medical History- Please elaborate on any of the conditions you mentioned above
Your answer
Family History- Please mark all that apply going all the way through to your grandparents- we will discuss further in clinic *
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List any current medication or supplements you are taking *
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Health Habits- check all that apply *
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Nutrition- please list typical meals throughout your entire day. What do you normally eat and in what amounts. Do you follow any specific diet? *
Your answer
Current Height *
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Current Weight *
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Reason for your office visit: Please write down the issue(s) you have been dealing with and the timelines for those issue(s) you are seeing Dr. Karla for. *
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What are your goals for your treatment? Please mark all that apply *
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Please tell me your specific pain/movement goals for your treatment. What are you looking to get out of your treatment(s) at Elevate Human Potential? *
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What types of care have you done in the past for the issue(s) you are coming in for today? *
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On a scale of 1-10 what is your current level of pain? *
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