Medical Intake Form Medical Intake Form Step 1 of 12 8% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneSex* Male Female Date of Birth* MM slash DD slash YYYY AgeMarital StatusSingleMarriedDivorcedWidowedEthnicityWhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answerOther Ethnicity Emergency Contact + Phone Number Enter your emergency contact with phone numberWho 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 conditionAre 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 CONTINUEThis 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 takeDo you have any known allergies?* Yes No List AllergiesPast Medical History (Ctrl Key to select multiple)AsthmaBladder DisorderBowel DisorderBronchitisDepressionDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLung DiseaseMental IllnessPolioRheumatismSeizureStrokeThyroidTuberculosisUlcerOtherNoneList 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)ArthritisBack ProblemsCancerDiabetesHeart AttacksHypertensionTuberculosisOtherNoneSelect all that applyList OtherDo 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 Select files Accepted file types: pdf, jpg, png, Max. file size: 128 MB, Max. files: 3. Signature RequirementI 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*
