Fakhoury Medical & Chiropractic Center

Ocala, Fl

Car Accident or Pain?
Call Us First!

+1 (352) 351-3413
[email protected]

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Home
Services
Interventional Pain Management
Conditions
Appointments
Intake Forms
Contact
Blog

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OCALA FL

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Specializing in serious car accident injuries in all of central florida

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Ocala's Top Chiropractor Office

Interventional Medicine

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Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date Of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email

Do you or have ever had any heart problems in your past or currently?

Yes

No

Have you ever in the past or do you currently take any blood thinners? (Asprin, Coumadin, Plavix)

Yes

No

Are you currently taking any anti-inflammatories? (Motrin, Advil, Naproxen, Mobic, etc)

Yes

No

Have you ever in the past or do you currently take any drugs to maintain normal heart rhythm?

Yes

No

If you have high blood pressure, has it ever been over 180/100?

Yes

No

Have you ever had a seizure?

Yes

No

Do you have allergies to iodine?

Yes

No

Have you had any IV (intravenous) dye injections?

Yes

No

Have you had any recent infections? (past three months)

Yes

No

Have you ever had an infection with MRSA (Methicillin-Resistant Staphylococcus Aureus)?

Yes

No

Do you have a history of retinal detachment or glaucoma?

Yes

No

Do you have diabetes? If so, are you insulin dependent?

Yes

No

Females Only: Is there any chance you could be pregnant?

Yes

No

Females Only: Are you currently breast feeding?

Yes

No

What is/are your main problems?

When did your problems starts? (weeks, months, years, specific dates)

What caused your symptoms? (fall, motor vehicle accident, etc)

How would you describe your pain? Choose all that apply

Achy

Dull

Sharp

Burning

Throbbing

Numbness

Which side hurts the most?

Achy

Right

Left

Both sides

The middle

Have you had any muscle spasms or tightness? If so, where?

Have you had any numbness and if so, where?

Does the pain tend to travel anywhere? (down the leg, arm, etc)

Over the past few weeks, is your pain

Improving

Worsening

Not getting any better

The same

Is the pain constant or intermittent (off and on)

Yes

No

What worsens the pain?

What reduces the pain?

How would you rate your pain level on a typical day from 1 to 10.

0 = No pain

1,2,3 = Minor aches

4,5,6 = Moderate

7,8,9 = Intense

10 = Emergency

What can you no longer do because of pain? (Goals of treatment)

Has this affected your sleep? Yes or No. If so, how many hours do you sleep.

Please list prior pain medicine

Have you ever had any of the following studies?

EMG (nerve study)

MRI

CT Scan

X-rays

Bone Scan

Have you ever had any of the following procedures or therapies?

Chiropractic

Physical Therapy

Epidural

Join Injections

Do you have a primary care physician? Please list name and location

Do you have a pharmacy you use? If so which pharmacy and where is it located?

What is your past/current medical history?

What is your past surgical history?

Are you taking any prescription medications? If yes please list.

Are you taking any over the counter medications? If yes, please list

Are you allergic to any medications? Please provide drug/reaction

Are you

Married

Single

Divorced

Widowed

Do you have any children?

Yes

No

Alcohol use

None

Social

Moderate

Daily (more than 2)

Do you smoke

Yes

No

How many packs a day

Have you ever taken/used illicit drugs?

Yes

No

What is your occupation? Full or Part Time

Are you working full or light duty?

Full

Light Duty

Not working

Have you tried to return to work?

Yes

No

Is there a lawyer involved?

Yes

No

Have you applied or intend to apply for social security?

Yes

No

Do you have any hobbies or activities that require a moderate level or physical activity?

Family History

Other

Have you had any of the following symptoms i nthe past month?

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

[email protected]
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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