Initial Intake Form To be used only for NEW PATIENTS Doctor/Intern Name Email Patient’s Name Occcupation —Please choose an option—sittingstandingcomputer userlaborer Age Sex —Please choose an option—MaleFemale Major complaint Secondary complaint BP How long has this bothered you? (Onset of pain) Where is the pain? (Local, does it travel?) How would you describe the pain? —Please choose an option—Deepburningstabbingsharp How often and intense is the pain? (scale of 1 – 10, 10 being very painful) What makes it better/worse? —Please choose an option—Body positionshotcoldnon weight bearing What caused the onset of the present problem? —Please choose an option—fall at workMVAliftingunknown Does this pain prevent you from doing anything? Name any other doctors you have seen regarding this problem. Were tests done or medications given to you for this pain? If yes, get a copy of the report. —Please choose an option—YesNo Are you currently taking over the counter or prescription medications? —Please choose an option—YesNo Are you taking any supplements or vitamins? —Please choose an option—YesNo Allergies? Accidents/surgeries? (what, when, how) Family history or related problems or disease? Frequency and type of regular exercise? Dietary habits CoffeeSodasFast foodDairyAlcoholCigarettesOrganicVegetarianHormone/Antibiotic free Sleep patterns (positions) Stomach/backArms overheadSidelyingW/Wo pillow supportRead/watch TV in bed Do you sleep through the night? How much water do you drink in a day? Do you have mercury fillings? —Please choose an option—YesNo Do you have any root canals? —Please choose an option—YesNo Initial intake form Doctor/Intern Name* Email* Patient’s Name* Occcupation*—SittingStandingComputer userLaborerAge*Sex*—MaleFemaleMajor complaint*Secondary complaint*How long has this bothered you? (Onset of pain)* Where is the pain? (Local, does it travel?)* How would you describe the pain?*—DeepBurningStabbingSharpHow often and intense is the pain? (scale of 1 – 10, 10 being very painful)* What makes it better/worse?*—Body positionshotcoldNon weight bearingWhat caused the onset of the present problem?*—Fall at workMVALiftingUnknownDoes this pain prevent you from doing anything?* Name any other doctors you have seen regarding this problem.*Were tests done or medications given to you for this pain? If yes, get a copy of the report.*—YesNoAre you currently taking over the counter or prescription medications?*—YesNoAre you taking any supplements or vitamins?*—YesNoAllergies?*Accidents/surgeries? (what, when, how)*Family history or related problems or disease?*Frequency and type of regular exercise?*Dietary habits* Coffee Sodas Fast food Dairy Alcohol Cigarettes Organic Vegetarian Hormone/Antibiotic free Sleep patterns (positions)* Stomach/back Arms overhead Sidelying W/Wo pillow support Read/watch TV in bed Do you sleep through the night?* How much water do you drink in a day?* Do you have mercury fillings?*—YesNoDo you have any root canals?*—YesNo
