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Where did you find us?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Which specialists do you see?
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Primary Care Physician
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Anything special we need to know
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Reason for your visit today
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Symptoms are a result of:
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Date you first noticed symptoms
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Frequency of Symptoms
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Rate your pain level
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What does it feel like?
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Where does it hurt?
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Other
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Does the pain affect other areas
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Factors that lessen pain
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Factors that worsen pain
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Previous steps taken for relief
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Anything else to tell Dr. Baxter
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Activities affected by condition
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Other daily activities affected
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Average amount of sleep (hourly)
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Describe your eating habits
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Additional Health Goals
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Family History - Mother
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Other illnesses or conditions
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Family History - Father
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Other illnesses or conditions
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Family History - Sister 1
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Other illnesses or conditions
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Family History - Sister 2
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Other illness or conditions
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Family History - Brother 1
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Other illnesses or conditions
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Family History - Brother 2
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Other illnesses or conditions
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Other Family Member
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Other Illnesses or Conditions
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Other hereditary health issues
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Surgical History - Please Select
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Other Surgical Operations
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Do you have pins/plates/screws?
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Where are they located?
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