Medical Intake Form Medical Intake Form Step 1 of 13 7% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneSex*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY AgeMarital StatusSingleMarriedDivorcedWidowedEthnicityWhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answerOther EthnicityEmergency Contact + Phone NumberEnter your emergency contact with phone numberWho is your employer + position Which of the following activities aggravate your condition: (Select all that apply)* Bending Coughing Lifting Lying Down Sexual Activity Sitting Sleeping Sneezing Standing Twisting Walking Other Other activities*Please list other activities that aggravate your conditionAre the symptoms:ImprovingGetting WorseAbout the SameIntermittent (come & go) What is your cheif complaint?*Is this condition due to:*Auto AccidentWork RelatedFallOtherDO 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* Do you take medication?*YesNoList medications you currently takeDo you have any known allergies?*YesNoList AllergiesPast Medical History (Ctrl Key to select multiple)AsthmaBladder DisorderBowel DisorderBronchitisDepressionDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseLung DiseaseMental IllnessPolioRheumatismSeizureStrokeThyroidTuberculosisUlcerOtherNoneList Other*Have you ever had surgery?*YesNoList 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?YesNoPacks per weekDo you drink alcohol?YesNoDrinks per weekDo you drink caffeine?YesNoDrinks per dayDo you exercise?YesNoHow many times per week?Do you use any recreational drugs?YesNoHow many times per week? How were you referred to our office? Friend/Family Google or search engine Billboard Physician Website Self Other Friend/Family* What area of the body are we treating? Arm Pain Left Arm Pain Right Hands Headaches Legs Low Back Pain Mid Back Pain Neck Pain Shoulder Pain Left Shoulder Pain Right Toes 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 Dell 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?*YesNoProvider NamePolicy NumberGroup Number File Upload- Please include a copy of your drivers license and insurance card. Drop files here or Accepted file types: pdf, jpg, png. 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 Signature*
