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Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

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Car Accident? Pain?

Call us

Online Paperwork

Updated Intake Form -Consent

Step 1 of 14

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Name(Required)
MM slash DD slash YYYY
Address(Required)
Emergency Contact
Name
Is there a chance you could become pregnant?
MM slash DD slash YYYY
Are you currently breastfeeding?
Employment Status
Duties
Have you missed any work?
MM slash DD slash YYYY
Have you had any of the following tests?
Have you had any of the following tests?
How would you describe your pain? Check all that apply
Over the past few days/weeks, is your pain:
What worsens or aggravates the pain? Check all that apply
What reduces or alleviates the pain? Check all that apply
Has this affected your sleep?
Do you feel rested upon waking up?
What medications are you taking including over the counter?
Current Medication Name
Dose
Frequency
This medication is for?
 
What is your past/current medical history? Check all that apply
What is your past surgical history?
Surgery (appendix, gallbladder removal, hernia, etc.)
Date of surgery
 
Does your family history include?
What activities have you had difficulties performing since your injury or accident? Check all that apply.
Have you had any of the following symptoms within the past month? Check all that apply
HEENT
Genitourinary
Musculoskeletal
Cardiopulmonary
Constitutional
CNS
Endocrine
Skin
Mental Health
Gastrointestinal
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    Find Us!

    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

    Contact Us

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

    Ocala, FL 34471

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    • About
      • Conditions
      • Services
      • Staff
      • Testimonials
      • History
    • Appointments
    • Auto Accident Intake Form
    • Auto-Accident Paper Work
    • Blog
    • Conditions
    • Health Insurance or Self Pay Forms
    • Hours Of Operation
    • Intervention Medicine Paperwork
    • Leave A Review
    • Medical Intake Form
    • Medical Release Form
    • New Medical Paperwork
    • New Patient Paperwork
    • Non Auto Accident Paperwork
    • Ocala Car Accident Doctor
    • Ocala Chiropractor
    • Ocala Chiropractor V1
    • Online Auto Accident Paperwork
    • Online Paperwork
    • Our doctors
    • Peripheral Neuropathy
    • Print Auto Accident Paperwork
    • Resources
    • Thank You Page
    • Veterans Choice
    • Website Privacy Policy
    • Before Your First Visit
    • Contact
    • Active Patient
    • New Patient
    • Chiropractic
    • Massage Therapy
    • Headaches
    • Low Back Pain
    • Mid & Upper Back Pain
    • Neck Pain
    • Shoulder & Arm Pain