Online Paperwork Updated Intake Form -Consent Step 1 of 14 7% Name(Required) First Middle Last DOB(Required) MM slash DD slash YYYY SS#(Required)Address(Required) 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 Email(Required) Phone(Required)Work Phone Emergency Contact First Last Phone Marital StatusMarriedSingleDivorcedWidowedName First Last Is there a chance you could become pregnant? No Yes Date of your last menstrual period? (LMP) MM slash DD slash YYYY Are you currently breastfeeding? No Yes EmployerOccupationEmployment Status Full Time Part Time Duties Full-Duty Light-Duty Job DutiesHave you missed any work? No Yes If Yes, explain Do you have a primary care provider? (PCP)NoYesName/Location(Required)Do you have a PHARMACY that you use?NoYesName/Location What caused your symptoms?Motor Vehicle AccidentFallSporting InjuryOtherOther:When did your problem(s) start or date of accident? (weeks, months, years, specific date):Were you treated at the emergency room or urgent care?NoYesLocationDate MM slash DD slash YYYY Have you had any of the following tests? EMG MRI CT Scan Bone Scan X-Ray Ultrasound EMG (when/where)MRI (when/where)CT Scan (when/where)Bone Scan (when/where)X-Ray (when/where)Ultrasound (when/where) Have you had any of the following tests? Chiropractic Physical Therapy Joint Injections Epidural Steroid Injections Chiropractic (when/where)Physical Therapy (when/where)Joint Injections (when/where)Epidural Steroid Injections (when/where) What are your main problems or complaints?How would you describe your pain? Check all that apply Achy Dull Sharp Burning Throbbing Numbness Over the past few days/weeks, is your pain: Improving Worsening Not getting any better The same What worsens or aggravates the pain? Check all that apply Standing Sitting Lying Down Walking Twisting Driving Leaning forward Heat Cold Coughing Sneezing Reaching Other OtherWhat reduces or alleviates the pain? Check all that apply Standing Sitting Lying Down Walking Twisting Driving Leaning forward Heat Cold Coughing Sneezing Reaching Other OtherHas this affected your sleep? No Yes Hours of sleep?Do you feel rested upon waking up? No Yes What medications are you taking including over the counter?Current Medication NameDoseFrequencyThis medication is for? Add RemoveDo you have an allergies?NoYesList allergiesWhat is your past/current medical history? Check all that apply Asthma Bronchitis Emphysema Tuberculosis Lung disease Seizures Heart Disease High blood pressure Stroke Diabetes Bladder disorder Bowel disorder Liver disease Kidney disease Thyroid Ulcers Acid reflux Polio Bipolar disease Depression Rheumatism Mental Illness Cancer Other Cancer DiagnosisOtherWhat is your past surgical history?Surgery (appendix, gallbladder removal, hernia, etc.)Date of surgery Add RemoveDoes your family history include? Genetic disease Heart disease Neurological disease Stroke Muscle disease Diabetes Alcoholism or illegal substances misuse Other Other family history What activities have you had difficulties performing since your injury or accident? Check all that apply. Bathing Dressing Showering Brushing teeth Brushing hair Caring for children Climbing stairs Sweeping/mopping Washing dishes Laundry Sexual activity Shopping Cooking Eating Sleeping Relationships Yard work Driving Homework Getting in/out of bed Walking to the bathroom Exercising Managing funds Engaging with family Working Other WorkingOtherDo you have any children?NoYesDo you have any hobbies or activities that require a moderate level of physical activity?Do you smoke?NoYesPacks per dayDo you drink alcohol?NoYesDrinks per weekDo you use/take drugs?NoYesDetailsDo you drink caffeine?NoYesCups per dayDo you exercise?NoYesTimes per week Have you had any of the following symptoms within the past month? Check all that apply HEENT Cardiopulmonary CNS Constitutional Endocrine Gastrointestinal Genitourinary Mental Health Musculoskeletal Skin HEENT double vision blurred vision recent changes in vision ringing in the ears recent changes in hearing ear drainage dizziness headaches (mild/severe) severe recurrent nosebleed difficulty swallowing Genitourinary burning on urination blood in urine changes in urinary habits difficulty holding urine penile or vaginal discharge penile or vaginal bleeding genital sores Musculoskeletal joint pain joint swelling grinding or joints locking of joints neck pain back pain Cardiopulmonary dull chest pain chest pressure /tightness chest palpitations (fluttering) shortness of breath at rest shortness of breath with exertion shortness of breath when lying flat cough coughing up (blood/mucus) wheezing swelling feet sever night sweats Constitutional fever chills night sweats loss of appetite unintentional weight loss CNS paralysis in arms or legs numbness in arms or legs loss of consciences seizures /new onset seizures jerking poor coordination changes in balance Endocrine increase thirst excessive sweating excessive urination excessive drinking hot/cold intolerance Skin loss of hair discoloration to skin dry sores itchiness rashes bruising wounds Mental Health anxiety depression frequent crying recent memory changes / loss aggression recent memory changes / loss restlessness at night Gastrointestinal abdominal pain nausea / vomiting vomiting blood black and tarry stool bloody stool clay-colored stools difficulty holding bowel movements dramatic change in bowel habits jaundice (yellowing of skin, eyes) diarrhea constipation ID Card & Health Insurance Drop files here or Select files Max. file size: 100 MB, Max. files: 4. Please upload your ID card front and back
