Initial Intake Form

Name*

First Last

Birthday*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone (Cell)

Phone (Other)

Cell Phone Provider (Unless Home Phone)

Preferred Contact Method

Select All
Regular Mail
e-Mail
Phone

# Children/Ages

Marital Status

Occupation

Employer

Work Phone

Insured's Name

First Last

Insured's DOB

Relation to Insured

Who referred you to us?

How else did you hear about us?

What is your major complaint?

When did the condition begin?

What do you think caused this condition?

Please describe the nature of the pain (Check all that apply)

Dull Ache
Sharp Stabbing
Burning
Pins/Needles
Numbness
Radiating

Associated Symptoms

Swelling
Stiffness
Clicking
Locking
Buckling
Weakness
Difficulty Using Stairs
Difficulty Walking

Is your present complaint due to a motor vehicle/workers comp accident?

Yes
No
Unsure

Date of Accident

Insurance Company & Claim Number

If so, please describe the accident:

Upload Police Report or Other Documentation Related to the Accident

Max. file size: 100 MB.

Have you had this or a similar condition in the past?

Do any positions make it feel worse?

Do any positions make it feel better?

Is this condition:

Improved
Unchanged
Getting Worse

Is this condition interfering with your... (Check all that apply)

Work
Sleep
Exercise
Daily Routine

Have you consulted any other physicians for THIS condition:

Yes
No

What physicians/therapists have you seen for this condition:

Have you had any of the following imaging studies for your problem? (check all that apply)

X-Ray
CT Scan
MRI
Other

Have you taken any medications for this problem?

Yes
No

If Yes, what medications?

Have you had previous treatments/surgeries for this problem?

Yes
No

If yes, what treatments/surgeries?

Family History: (Include relation and age of onset if known)

High Blood Pressure	Diabetes Meliltus	Heart Disease	Stroke	Cancer	Arthristis	Osteoporosis	Asthma	COPD	Other

Mental Work

Heavy
Moderate
Light

Hours Per Day

Physical Work

Heavy
Moderate
Light

Hours Per Day

Activity Level (Exercise)

INACTIVE (normal activities of daily living)
LIGHT (some activity; walking, gardening, occasional weekend recreational exercise)
MODERATE (regular 3x per week moderate exercise, weekend athletics)
VIGOROUS (regular 3-5x per week vigorous exercise and/or athletics weekly)
INTENSE (competitive daily vigorous sports training)

Smoking History

Current
Previous
Never

Cigarettes Per Day / Number of Years

Alcohol Consumption

Beer
Liquor
Wine
None

Servings Per Week / Number of Years

Are you currently taking any medication?

Yes
No

List Medications you Currently Take

Medication name	Dosage	Directions

Do you have any allergies?

Yes
No

List Allergies

Food	Environmental	Medication

Upload files here such as a script, ins card, and/or other records etc. (only jpg, gif, png, pdf, zip files allowed)

Drop files here or

Accepted file types: jpg, gif, png, pdf, zip, Max. file size: 100 MB, Max. files: 10.

Email

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