New Patient Intake Form

Intake Form — New Patient

Name *

Address *

Phone *

Mobile *

Date of Birth *

Occupation

Email *

Reason for seeking Treatment? *

For each condition, select whether it applies to you, a family member, both, or neither.

Other

What medications are you taking? Please list both prescription and over the counter medications *

If you had an illness in the last 3 weeks, please explain

How much alcohol do you drink in the course of a week? *

Do you use recreational drugs? If yes, what, how much and how often? *

How much caffeine do you consume daily? (including soft drinks, coffee, tea and chocolate) *

Do you have a pacemaker, organ transplant, joint replacements, or metal implants?

Have you had any medical tests done recently? (i.e. X-rays, CT scans, MRI's, ultrasounds, bone scan etc..)

Have you had any lab work done? If so do you know the results?

What surgery have you had done in your life? Please list the year it was done as well.

Please list any allergies that you have

What is your history of injury? (i.e. car accidents, slip and fall, sports injury, etc.)

Have you had any illness within the last 3 weeks? (e.g. colds, flu’s, infections) *

Yes No

Do you smoke or chew tobacco? *

Yes No

I consent to treatment and confirm the information provided above is accurate to the best of my knowledge. *

Your Full Name *

Today's Date *

Digital Signature *