Patient Information
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Today's Date * (## / ## / ####)
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Birth Date * (## / ## / ####)
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Home Phone (### - ### - ####)
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Work Phone (### - ### - ####)
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Cell Phone (### - ### - ####)
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Contact Person to Notify in Case of Emergency
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Phone Number * (### - ### - ####)
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Phone Number (### - ### - ####)
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Phone Number (### - ### - ####)
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Patient Employment Information Parent Information for Students and Minors
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Employer (indicate if student) *
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This information is required for patients who are students and/or minors *
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Parent Information for Students and Minors
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Parent's Work Phone & Ext.
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Insurance Information
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Subscriber's Birth Date * (## / ## / ####)
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Patient Relationship to Subscriber *
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Subscriber's Birth Date (## / ## / ####)
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Patient's Relationship to Subscriber
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Is this a Worker's Compensation case? *
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Is this a No-Fault claim (auto accident)? *
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Is this a Legal/Third Party Liability case? *
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Medical History
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List all allergies * (drugs, latex, tape, food)
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List all medication names (include non-prescription) *
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List previous surgeries and what year they were performed *
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**If more than 12 medications please bring in a list at check-in. Please do not bring in your pills.
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**If more than 6 surgeries please bring in a list at check-in.
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To your knowledge, do you have now or have you ever had any of the following: *
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Yes No
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Cancer
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Diabetes
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Heart Disease/Failure
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Heart Murmur/Mitral Valve Prolapse
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High Blood Pressure
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AIDS/HIV Positive
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Asthma
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Bleeding/Bruising Tendencies
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Lung Disease/Emphysema
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MRSA / VRE Infection
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Stroke
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Thyroid Disease
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Have you ever smoked?
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Yes No
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Arthritis
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Blood Transfusion(s)
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Blood Clots (DVT)
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Phlebitis
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Kidney Disease
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Liver/Disease/Hepatitis
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Stomach Ulcer / GERD
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Tuberculosis
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Hearing or Vision Problems
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Nose or Throat Problems
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Epilepsy / Seizures
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Depression/emotional illness/panic attacks
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Sleep apnea
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Insomnia
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Could you be pregnant?
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Other medical condition not already listed max 50 characters
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Have you ever had complications with surgery? *
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If yes, explain
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Any bleeding disorder problems with you or your relatives during or after surgery? *
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If yes, explain
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Any anesthesia problems with you or your relatives during or after surgery? *
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If yes, explain
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Have you had a bone density test? *
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If yes, when
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Regarding Today's Visit
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What area of the body are you scheduled to be seen for? *
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Which side (right, left, bilateral)? *
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Give a brief description of the problem. i.e. What were you doing? How did the injury occur? *
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Date of Injury (if no injury write N/A) * (## / ## / ####)
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How long have you had this problem?
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Pain level at time of injury (1-barely any, 10-unbearable)
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What tests have you had done for this problem and when? max 80 characters
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Have you had a previous injury or trauma to this area? *
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Have you had any surgery to this area? *
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If yes, what and when?
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Have you seen someone else for this problem? *
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If so, whom?
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Are you right or left handed? *
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Confidentiality / HIPAA
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Yes No NA
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May we leave a message at your home requesting a return call? *
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May we leave a message at your home regarding appointment scheduling? *
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May we leave a message at your home with test results and/or medical advice? *
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May we leave a message at your work requesting a return call? *
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May we leave a message at your work regarding your health care? *
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May we leave a message on your cell requesting a return call? *
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May we leave a message on your cell regarding appointment scheduling? *
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May we leave a message on your cell with test results and/or medical advice? *
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May we speak with someone other than you regarding you treatment? If yes, please list below: *
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May we speak with your employer regarding your treatment? *
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May we fax information to your employer regarding your treatment? (For example, work release form etc.) *
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You must review your information before it can be submitted. Please press the button below when you are ready to review your information. On that page you will submit your information.
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Patient feedback regarding our online form: Did you find the online form easy to use?
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Yes
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Feedback Comments:
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No
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