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Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

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Car Accident? Pain?

Call us

Intervention Medicine Paperwork

Interventional Medicine

Step 1 of 12

8%
Do you or have ever had any heart problems in your past or currently?
Have you ever in the past or do you currently take any blood thinners? (Asprin, Coumadin, Plavix)
Are you currently taking any anti-inflammatories? (Motrin, Advil, Naproxen, Mobic, etc)
Have you ever in the past or do you currently take any drugs to maintain normal heart rhythm?
If you have high blood pressure, has it ever been over 180/100?
Have you ever had a seizure?
Do you have allergies to iodine?
Have you had any IV (intravenous) dye injections?
Have you had any recent infections? (past three months)
Have you ever had an infection with MRSA (Methicillin-Resistant Staphylococcus Aureus)?
Do you have a history of retinal detachment or glaucoma?
Do you have diabetes? If so, are you insulin dependent?
Females Only: Is there any chance you could be pregnant?
Females Only: Are you currently breast feeding?
How would you describe your pain? Choose all that apply
Which side hurts the most?
Over the past few weeks, is your pain
Is the pain constant or intermittent (off and on)
How would you rate your pain level on a typical day from 1 to 10.
Have you ever had any of the following studies?
Have you ever had any of the following procedures or therapies?
Are you
Do you have any children?
Alcohol use
Do you smoke
Have you ever taken/used illicit drugs?
Are you working full or light duty?
Have you tried to return to work?
Is there a lawyer involved?
Have you applied or intend to apply for social security?

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Hours of Operation

Our Office Hours Are As Follows:

  • Monday 7:30 to 6:00
  • Tuesday 7:30 to 6:00
  • Wednesday 7:30 to noon
  • Thursday 7:30 to 6:00
  • Friday 7:30 to 6:00
  • Saturday Closed

Contact Us

Phone: (352) 351-3413
Fax: (352) 629-6667
Address:1009 SW 16th Lane

Ocala, FL 34471

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  • About
    • Staff
    • Testimonials
    • Services
      • Chiropractic
      • Massage Therapy
    • Conditions
      • Headaches
      • Low Back Pain
      • Mid & Upper Back Pain
      • Neck Pain
      • Shoulder & Arm Pain
    • History
  • Appointments
    • Active Patient
    • New Patient
  • Auto Accident Intake Form
  • Blog
  • Health Insurance or Self Pay Forms
  • Home
  • Hours Of Operation
  • Intervention Medicine Paperwork
  • Leave A Review
  • Medical Intake Form
  • New Patient Paperwork
  • Ocala Car Accident Doctor
  • Ocala Chiropractor
  • Online Auto Accident Paperwork
  • Our doctors
  • Peripheral Neuropathy
  • Print Auto Accident Paperwork
  • Resources
  • Thank You Page
  • Veterans Choice
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  • Before Your First Visit
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