Fakhoury Medical & Chiropractic Center

Ocala, Fl

Car Accident or Pain?
Call Us First!

+1 (352) 351-3413
head2toecare@gmail.com

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Intake Forms
Contact
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Phone-volume Envelope

Non Auto

accident

paperwork

OCALA FL

Discover Non auto accident intake

unique model of multidisciplinary practices under one roof

Online new Patient
medical Intake Form

Ocala's Top Chiropractor Office

Medical Intake Form

Form for Medical Patients

Step 1 of 12

8%

Name*
Prefix First Middle Last Suffix
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Work Phone
Cell Phone
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Age
Marital Status
Ethnicity
Other Ethnicity
Emergency Contact + Phone Number
Enter your emergency contact with phone number
Who is your employer + position

Which of the following activities aggravate your condition: (Select all that apply)*
- Standing
- Sneezing
- Coughing
- Twisting
- Lying Down
- Sitting
- Sexual Activity
- Bending
- Lifting
- Walking
- Other
Other activities*
Please list other activities that aggravate your condition
Are the symptoms:
- Improving
- Getting Worse
- About the Same
- Intermittent (come & go)

What is your chief complaint?*
Is this condition due to:*
- Auto Accident
- Work Related
- Fall
- Other
DO NOT CONTINUE
This form is for NON ACCIDENT ONLY. Please return to the previous page and select Accident Intake Form. You will not be able to submit this form.
Please list other*

Date of Accident*
MM slash DD slash YYYY
Were you treated at the ER?*
- Yes
- No
Name of Facility
Were MRIs, CTs, Ultrasounds or Xrays done?*
- Yes
- No
Where?*
Primary Care Physician
Physician Phone

Do you take medication?*
- Yes
- No
List medications you currently take
Do you have any known allergies?*
- Yes
- No
List Allergies
Past Medical History (Ctrl Key to select multiple)
List Other*
Have you ever had surgery?*
- Yes
- No
List your surgery*

Do you have a family history with any of the following? (Ctrl Key to select Multiple)
Select all that apply
List Other
Do you smoke?
- Yes
- No
Packs per week
Do you drink alcohol?
- Yes
- No
Drinks per week
Do you drink caffeine?
- Yes
- No
Drinks per day
Do you exercise?
- Yes
- No
How many times per week?
Do you use any recreational drugs?
- Yes
- No
How many times per week?

Have you experienced any of these symptoms? Select all that apply
- Double Vision
- Blurred Vision
- Ringing in the ears
- Dizzy
- Poor Hearing
- Severe Headache
- Sever Recurrent Nose Bleeds
- Difficulty Swallowing
Have you experienced any of these symptoms? Select all that apply
- Dull Chest Pain
- Pressure/Tightness
- Chest Palpitations (fluttering)
- Shortness of Breath at Rest
- Shortness of Breath with Exertion
- Shortness of Breath when Lying Flat
- Coughing
- Coughing up blood
- Swelling Feet
- Sever Sweating at night

Have you experienced any of these symptoms? Select all that apply
- Abdominal Pain
- Vomiting
- Vomiting Blood
- Black & Tarry Stool
- Bloody Stools
- Clay colored stools
- Loss of Bowel Control
- Dramatic change in bowel habits
- Jaundice (Yellowing of the skin or eyes)
Have you experienced any of these symptoms? Select all that apply
- Burning on urination
- Blood in the urine
- Urination frequency
- Loss of bladder control
- Penile or vaginal discharge
- Penile of vaginal bleeding
- Genital Sores

Have you experienced any of these symptoms? Select all that apply
- Joint Pain
- Joint Swelling
- Grinding of joints
- Locking of joints
- Neck pain
- Back pain
Have you experienced any of these symptoms? Select all that apply
- Fever
- Chills
- Night Sweats
- Loss of appetite
- Unintentional weight loss

Have you experienced any of these symptoms? Select all that apply
- Paralysis in arms or legs
- Numbness in arms or legs
- Loss of consciousness
- Seizures
- Tremors
- Jerking
- Poor coordination
Have you experienced any of these symptoms? Select all that apply
- Loss of hair
- Dry sores
- Itchiness
- Rashes
Where do you have dry sores?*
Have you experienced any of these symptoms? Select all that apply
- Increase Thirst
- Excessive urination
- Excessive Drinking
- Hot/Cold Intolerance
- Excessive Sweating

Do you have insurance?*
- Yes
- No
Provider Name
Policy Number
Group Number

File Upload- Please include a copy of your drivers license and insurance card.
Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 100 MB, Max. files: 3.
Signature Requirement
I clearly understand that if I am accepted as a patient at Fakhoury Medical and Chiropractic Center, I authorize them to proceed with the treatment as necessary. Any risks regarding such treatment will be explained upon request. I also understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. In the case insurance verification is obtained, insurance claims may be filed. I understand that the filing of insurance is not a guarantee of payment, and I remain responsible for the entire amount due. I also understand that if I terminate my care and treatment, any fees for professional services rendered me prior to my termination of care will be immediately due and payable. In the extend of default, I promise to pay legal interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection. I hereby attest that the above and all following information is true to the best of my knowledge.*
- I agree
Full Legal Name
Date
MM slash DD slash YYYY
Signature*

Ocala Chiropractor Office

Print New patient Intake

Medical and Chiropractic Center

Cash or Insurance Paperwork

NOTE: Please print this paperwork

Call(352) 351-3413

OCALA-BASED MEDICAL / CHIROPRACTIC OFFICE

About

Fakhoury Chiropractic Office has been serving Marion County over the years with a unique multi-disciplinary approach for treatment of musculo-skeletal pain such as headaches, neck pain, lower back pain, arm/leg pain and injuries from accidents

@ Fakhourychiro

Contact

head2toecare@gmail.com
Phone: (352) 351-3413
Fax: (352) 629-6667
Address:1009 SW 16th Lane Ocala, FL 34471

Work Hours

Monday 7:30 to 5:30
Tuesday 7:30 to 5:30
Wednesday 7:30 to 12:00
Thursday 7:30 to 5:30
Friday 7:30 to 5:30

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