FORMS

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    Lets Get Started

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    Your Information

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    Employment Information

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    Health Information

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    Symptoms

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    Pain Measurement

    New Patient Information (*=Required Field)






























    MaleFemale

    SingleMarriedSeparatedDivorcedWidowed


























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    Employment


    YesNoOther

    YesNo












    Health Insurance Information







    Auto Insurance Information


    Auto InsurancePersonal Injury Protection (PPP)Uninsured MotoristMed Pay












    Third Party Liability (if applicable)










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    Review of Symptoms


    FaintingLow LibidoPoor AppetiteFatigueSudden Weight GainSudden Weight LossWeaknessNone of the Above

    AsthmaApneaEmphysemaHay FeverShortness of BreathPneumoniaNone of the Above

    High Blood PressureLow Blood PressureHigh CholesterolPoor CirculationAnginaExcessive BleedingNone of the Above

    Anorexia/BulimiaUlcerFood SensitivitiesHeartburnConstipationDiarrheaNone of the Above

    Kidney StonesInfertilityBedwettingProstate IssuesErectile DysfunctionPMS SymptomsNone of the Above

    Skin CancerPsoriasisEczemaAcneHair LossRashNone of the Above

    Blurred VisionRinging in EarsHearing LossChronic Ear InfectionLoss of SmellLoss of TasteNone of the Above


    Thyroid IssuesImmune DisordersHypoglycemiaFrequent InfectionSwollen GlandsLow EnergyNone of the Above

    History

    Mother's Family History(if living)
















    Father's Family History(if living)

















    Social History
















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    Work History



    Job Requirements (Lifting)

    Have you missed work because of this accident?

    If you have missed work because of this accident, by how many days?

    Who took you off work?

    If other, who took you off of work?

    Do you continue to work despite the pain?

    Did you lose your job as a result of this accident?

    Are you working light or restricted duty?

    Dominant Hand

    Past Medical History

    Illness




    Surgeries

    Any surgeries PRIOR to injury?







    Medications & Allergies

    Please list below all prescription, over-the-counter or natural supplements you are taking

    Are you allergic to any medications?

    If yes, please list

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    Functional Rating Index

    In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.

    Rate Your Pain Intensity

    Rate Your Sleeping

    Personal Care (washing, dressing, etc.)

    Travel (driving, etc.)

    Working

    Recreation

    Frequency of Pain

    Lifting

    Walking

    Standing

    Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.

    Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!