Intake Form

Personal Information
Employed Retired Student
Yes No
Parent / Guardian / Spouse Information

Parent Guardian Spouse
Condition / Injury Information
No Yes
No Yes
No Yes
Insurance Information
Privacy Practices
No Yes
No Yes
Authorization

Medical History Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

PERSONAL INFORMATION
Single Married Divorced Widowed
A New Patient To The Practice An Established Patient To The Practice
MEDICATION

Yes No
Yes No
Yes No
ALLERGIES
Yes No
Yes No
  • Latex
  • Nickels / Metals
  • Cinnamon
  • Poultry
  • Shell Fish
  • Seasonal
  • Other
MEDICAL HISTORY

 Please check any conditions that you have had in the past or have currently

High Blood Pressure High Cholesterol
History of Blood Clot Atrial Fibrillation Other
Atrial Cardiac Stent Bypass Surgery
Pacemaker Heart Murmur Stroke
Mitral Valve Prolapse
Congestive Heart Failure Anemia
Heart Attack
Other
Asthma COPD Sleep Apnea
Other
Osteoarthritis Gout
Osteoporosis Rheumatoid Arthritis
Lupus Psoriatic Arthritis
Other
Esophageal Reflux Ulcer
Liver Disease Hepatitis
Other
Renal / Kidney Disorder Prostate Disorder Urinary Tract Disorder Urinary Incontinence? No Yes   If Yes, Type:
Psoriasis Other
Lyme Disease MRSA (Drug Resistant Infection) HIV Disease STD
Other
Migraine Headache Epilepsy Seizures Depression Anxiety
Bipolar Disorder Alcohol Dependence
Drug Dependence Dementia
Other
Diabetes Gestational Diabetes HYPO-Thyroidism
HYPER-Thyroidism HIV Infection
History of Cancer :
No Yes  If Yes Please List:

Other :
Possible Pregnancy? No Yes
Last Menstrual Period:
Menopause? No Yes
Other :
 
SURGICAL HISTORY

Orthopedic:

UPPER EXTREMITY
Arthroscopic surgery
Rotator Cuff Repair
Shoulder replacement
Other
Arthroscopic surgery
Cubital tunnel release
Other
Carpal tunnel surgery
Arthroscopic surgery wrist
Nerve and vessel hand microsurgery
Amputations
Other
LOWER EXTREMITY:
Hip arthroscopy
Hip replacement
Realignment procedure
Other
Knee arthroscopy
ACL reconstruction
ACL repair
Knee replacement
Meniscus or cartilage transplant
Realignment procedure
Other
Ankle arthroscopy
Ankle ligament reconstruction or repair
Podiatric foot surgery
Other foot or ankle surgery
Epidural or any pain management spine injection
Laminectomy
Discectomy
Spinal fusion
Other type of spine surgery

Non-Orthopedic Surgery:

Cataract Surgery
Tonsillectomyx
Adenoidectomy
Wisdom Tooth Extraction
Thyroid Surgery
Cardiac Stent Placement
Open Heart: Bypass Surgery
Cardiac Pacemaker
Appendectomy
Gallbladder Surgery
D & C
C-Section
Hysterectomy
Prostate Surgery
Hernia Repair Surgery
Other
No History of Surgery
FAMILY HISTORY
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
High Blood Pressure
Diabetes Mellitus
High Blood Sugar
DVT/Blood Clot
Bleeding Disorder
Stroke
Asthma
COPD
Osteoarthritis
Osteoporosis
Cancer
ACTIVITY LEVEL
INACTIVE (Normal activitied of daily living)
LIGHT (Some activity; walking, gardening, occasional weekend recreational exercise)
MODERATE (regular 3x per week moderate exercise, weekend athletics)
VIGOROUS (regular 3-5x per week vidorous exercise and/or athletics weekly)
INTENSE (competitive daily vigorous sports training)
SOCIAL HISTORY
What do you do for work:
Yes No
Yes No
PAIN LEVEL
 Please describe your current pain level
No Hurt Hurts Little Bit Hurts Little More Hurts Even More Hurts Whole Lot Hurts Worst
REVIEW OF SYMPTOMS
 Have you experienced any of the following symptoms over the past 6 months?
Recent Illness Recent Weight Gain(lbs)
Recent Weight Loss(lbs) Fever
Chills Neck Pain/Stiffness Cough
Shortness of Breath
Chest Pain or Discomfort Palpitations
Hearburn / Indigestion Nausea
Vomiting Abdominal Pain
Diarrhea Urinary Symptoms Skin Rash
Easy Bleeding Easy Bruising Tendency
Dizziness Motor Disturbances
Sensory Disturbances Joint Pain Stiffness Joint Stiffness Anxiety Depression
Other

Injury Form

Please fill this form as accurately as possible to the best of your ability to help us treat you.

Patient Name:

How you were injured?

Car Accident
Hit By Car
Motorcycle Accident
Work related injury / Workman Comp
School/ sports injury. - Which school or Sports Team?
Other (please describe):

Date of injury:

Body Parts injured (include right or left):

Please describe how the injury occurred and where on the date you listed above:

Signature of Patient or Guardian:


Covid-19 Screener

Please fill this form as accurately as possible to the best of your ability to help us treat you.

All patients phone screened prior to scheduling Initial appt

Name :

 Are you experiencing ANY new (or worsening) fever cough, shortness Of breath, sore throat, loss of taste/ smell, or abdominal pain/ diarrhea?

 In the last 14 days, have you had contact with someone with or has confirmed COVID-19 exposure or diagnosis?

 Have you travelled overseas in the past 2 weeks?


We do require that:

  • All patients wear a mask when in the facility
  • Temperature screening will be done for everyone entering our office
  • Gloves be wore at all times when in the facility (we provide gloves)

Are you okay with that?

  • All patients to use hand sanitizer upon entry to the Office
  • All patients need to have a mask on when entering the Office and wear gloves after sanitizing their hands
  • All patients screened upon entry to the Office - verbal screen (see above)
  • Temperature will be taken on entry
  • Every visitor / staff wears a mask and gloves at all times when in the clinic
  • Face shield wore by all staff at all times
  • Staff to self monitor symptoms - temp check every night and 2-3 hours prior to shift
  • Staff exposed to known suspect of COVID-19 wear masks at all the times
  • Social distancing to be practiced amongst staff