Intake Questionnaire

Patient Full (Legal) Name

Intake Form Completion Date

Patient Information

Social Security Number

Age

Patient Marital Status

Married

Single

Widowed

Divorced

Patient Best Email Address *

Best Phone *

Date of birth

Street Address

City

State

Postal code

_________________________________________________________________________________________________________________________________________________________________________________

Employer

Occupation

Emergency Contact Information

In Case of Emergency, Notify

Relationship

Emergency Contact Phone

Medical Information

_________________________________________________________________________________________________________________________________________________________________________________

DO YOU HAVE A HISTORY OF ANY OF FOLLOWING DISEASES?

Sciatica

Gout

High Blood Pressure

Stroke

Active Cancer

Paralysis

Seizures

Arthritis

Are You Pregnant?

Yes

No

If Yes, First Day of Last Menstruation Cycle

Your Current Primary Care Physician

Physician Name

Phone

Approximate Date of Last Visit

Physician Address

Referring Physician

Referring Physician Name

Referring Physician Phone

Referring Physician Address

HIPPA Compliance

Our office is required by law to maintain the HIPAA Notice of Privacy Practices. This notice explains our legal duties and privacy practices with respect to your protected health information. The signature below acknowledges that I have read this Notice of our Privacy Practices. A copy will be provided to me upon request.

Intake Patient Signature

Clear

Intake Patient Signature Date

I hereby certify that, to the best of my knowledge, the provided information is true and accurate. I agree to terms & conditions provided by the company. By providing my phone number and email, I agree to receive text messages and emails from the business.