Fakhoury Medical & Chiropractic Center
Ocala, Fl
Car Accident or Pain?
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+1 (352) 351-3413
head2toecare@gmail.com
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Medical Intake Form
Form for Medical Patients
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*
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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?
*
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No
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Past Medical History (Ctrl Key to select multiple)
Asthma
Bladder Disorder
Bowel Disorder
Bronchitis
Depression
Diabetes
Heart Disease
High Blood Pressure
Kidney Disease
Lung Disease
Mental Illness
Polio
Rheumatism
Seizure
Stroke
Thyroid
Tuberculosis
Ulcer
Other
None
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*
Have you ever had surgery?
*
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No
List your surgery
*
Do you have a family history with any of the following? (Ctrl Key to select Multiple)
Arthritis
Back Problems
Cancer
Diabetes
Heart Attacks
Hypertension
Tuberculosis
Other
None
Select all that apply
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Do you smoke?
Yes
No
Packs per week
Do you drink alcohol?
Yes
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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?
*
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Group Number
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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
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