Intake Form

Please complete all required fields!

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information.
We'll see you soon!

Patient Information

First name (*)

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Middle Initial

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Last name (*)

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Your Email Address (Responsible Party) (*)

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Mailing Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Home Phone Number (*)

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Cell Phone Number

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Sex (*)

Male Female

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Marital Status (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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*This information is requested due to Healthcare Reform laws dictated by Congress.

Are you pregnant?(*)

No Yes

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Are you nursing?(*)

No Yes

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Primary Care Physician (*)

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Physician Phone Number (*)

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Date last seen: Month

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Day

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Year

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Pharmacy

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Pharmacy Phone Number

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Who referred you to our office? (*)

Who?

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Other

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Other Specialty Physicians - List name and Specialty (e.g., cardiologist, rheumatologist, etc.)

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Primary Reason for Visit (*)

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Duration of Condition (*)

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What helps / makes it worse?

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Is it limiting your activity level? (*)

Yes No

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Secondary problem (if there is one)

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Please list any drug allergies and your reaction to each medication (e.g, rash, hives, etc.) (*)

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Any METAL allergy (such as nickel, stainless steel, titanium)?

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List Medications You Take (*)

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Specify other

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If you have cancer, please list type and treatment

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Please list other past surgeries and year surgery was performed (*)

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Is your problem related to a Workman’s Comp injury or an auto/other accident?(*)

No Yes

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Do you drink alcohol?(*)

Never Past Yes

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How often?

Daily 1-2 x Week 1-2 x Month 1-2 x Year

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Do you smoke, vape or use chewing tobacco?(*)

Never Past Yes

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Please specify

Cigarettes Cigars Chewing Tobacco Vaping

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How many per day?

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Method of Quitting

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Do you have/have had a substance abuse problem?(*)

Never Past Yes

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Please specify

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Family History

Which family members had the below medical conditions? (father, mother, sibling, etc.)

Diabetes

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Stroke

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Cancer

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Arthritis

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Heart Attack

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Hypertension/High Blood Pressure

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Insurance Information

Subscriber's Name (*)

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Subscriber's D.O.B. (*)

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Patient's Relation to the Subscriber (*)

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HMO (*)

Yes No

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Primary Insurance (*)

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Policy Number (*)

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Secondary Insurance

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Secondary Policy Number

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Occupation (*)

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Employer (*)

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City

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State

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Zip-Code

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Emergency Contact

First Name (*)

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Last Name (*)

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Relationship to Patient (*)

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Phone (*)

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Responsible Party (if minor patient)

First Name

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Last Name

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Relationship to Patient

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Date of Birth: Month

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Day

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Year

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Please sign with your initials (*)

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Intake Form

Patient Information

Social History

Family History

Insurance Information

Emergency Contact

Responsible Party (if minor patient)

Consent for Treatment and Acknowledgement of Policies

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