|
Where did you find us?
|
|
|
Which specialists do you see?
• • •
|
|
|
Who referred you?
|
|
|
Do you use online scheduling?
|
|
|
Want access to online portal?
|
|
|
Anything special we need to know
|
|
|
|
|
|
Describe the reason for your visit:
|
When did your symptoms begin?
|
|
Frequency of your discomfort during the day
• • •
|
|
|
What helps relieve your discomfort?
• • •
|
Other (please describe)
|
|
What activities are limited by your discomfort?
• • •
|
Other (please describe)
|
|
|
|
|
Who have you seen for your symptoms?
• • •
|
Other (please describe)
|
|
Still receiving treatment from another provider?
|
|
|
Specify the approximate date of your most recent
|
|
|
Physical (Month/Year)
/
|
Dental X-Rays (Month/Year)
/
|
|
CT Scan (Month/Year)
/
|
Spinal X-Ray (Month/Year)
/
|
|
MRI (Month/Year)
/
|
Body diagram
|
|
What type of exercise do you perform?
|
Height (Feet and inches) and Weight (in lbs)?
/
|
|
List prescription/over-the-counter/supplements
|
Surgical procedures/times you were hospitalized
|
|
Consenting to the following procedures?
• • •
|
Other
|
|
Parent/Legal Guardian's name:
|
Address
|
|
Home Phone Number:
|
Work Phone Number:
|
|
Other Contact Phone Number:
|
|
