Patient Intake Form - Advanced Spinal Care printable pdf download

Patient Intake

Today’s Date:______/______/_______

Name: ______________________________________________ Age____________ Date of Birth_____________________________

Local Address__________________________________________ City___________________ State____ Zip___________________

Out of Town Address______________________________________ City___________________ State____ Zip_________________

Marital Status_________ Sex_______ S.S.# __________________ Home Phone_________________ Cell. Phone_________________

Email Address: _____________________________________________ Employer_________________________________________

Occupation _________________ Address/Phone ______________________________ Spouse _____________________________

Emergency Contact_______________________________Phone__________________Relationship_____________________________

How did you hear about our office?

Yellow Pages

Drive By

Walk-In

Internet

Referral (Please tell us who) ___________________

Other: ____________________

Health Insurance Information

Primary Insurance ________________________________ Policy Holder’s Name _________________________ DOB ____________\\

Policy Holder’s Relationship to Patient _________________ Policy Holder’s Employer ______________________________________

Accident Information (SKIP this section if you were not involved in an accident)

Is your condition due to an:

Auto Injury

Work Injury

Slip and Fall

Other Accident (describe below)

Date of Accident_____________________________ Place (City/State)_________________________________________________

Auto/Work Insurance Company_________________________ Insured’s Name and DOB____________________________________

If Auto Injury, have you reported the accident to your insurance company?

Yes Claim #___________________________

If Work Injury, have you reported the accident to your supervisor/boss?

Yes Claim #___________________________

If Slip and Fall or Other Type of Injury, please describe: ______________________________________________________________

Do you have an Attorney for your Auto or Work Comp. injury

Yes

Please provide Attorney Name, address and phone # ________________________________________________________________

Current complaint

I. Please list your worst complaint: ________________________________ How long have you had it: _________________________

How did it start: _________________________

A) Is it:

Improving

Worsening

Staying the Same B) Is it:

Mild

Moderate

Severe C) What worsens it:

General activity

Moving Wrong

Bending

Lifting

Walking

Sports

Getting up from a chair

Using a computer/desk work

Other: ________________________ D) What makes it better:

Rest

General Activity

Ice Packs

Heating Pad

OTC Meds

Rx Meds

Massage

Chiropractic

Other:___________________ E) Is it worse in the:

After day wears on

Steady

Off and on F) Is the symptom:

Dull and Achy

Tight and Stiff

Sharp and Stabbing

Numb and Tingly

Shooting

Burning

Cramping

II. Please list your 2

worst complaint: ________________________________ How long have you had it: ________________________