Intake Form Patient Information Form Patient Information Form Full Name * DOB * Current Age * Sex * Male Female Reason For Visit * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home Phone Cell Phone * Email * Martial Status: * Married Single Divorced Widowed Separated Occupation of Patient Employer/Company Name Spouse's Name Spouse's Employer Do You Drink? * Yes No Do You Smoke? * Yes No Height * Weight * In Case Of An Emergency: Whom Should We Contact? Name Phone Relationship Health History Check symptoms you currently have or have had in the past year. General Chills Depression Dizziness Fainting Fever Forgetfullness Headache Loss of Sleep Loss of Weight Nervousness Sweats Eyes Crossed Eyes Double Vision Vision - Flashes Vision - Halos Blurred Vision Ears/Nose/Throat Earache Ear Discharge Ringing in Ears Loss of Hearing Hay Fever Sinus Problem Nose Bleeds Bleeding Gums Hoarseness Difficulty Swallowing Persistent Cough Respiratory Shortness of Breath Couch Congestion Distress Sputum Endocrine Weight Gain Weight Loss Hoarseness Heat Intolerance Cold Intolerance Breast Changes Hair Changes Extreme Thirst Genito-urin Blood in Urine Frequent Urination Lack of Bladder Control Painful Urination Gastrointestinal Poor Appetite Bloating Bowel Changes Constipation Diarrhea Excessive Hunger Excessive Thirst Gas Hemorrhoids Indigestion Nausea Rectal Bleeding Stomach Bleeding Stomach Pain Vomiting No Blood Vomiting Bleeding Cardiovascular Chest Pain High Blood Pressure Irregular Heart Beat Low Blood Pressure Poor Circulation Rapid Heart Beat Swelling of Ankles Varicose Veins Women Only Abnormal Pap Smear Bleeding Between Periods Breast Lumps Extreme Menstrual Pain Hot Flashes Nipple Discharge Painful Intercourse Vaginal Discharge Other Date of Last Menstrual PeriodDate of Last Menstrual Period Date of Last Pap SmearDate of Last Pap Smear Have you had a mammogram?Have you had a mammogram? Are you pregnant?Are you pregnant? Number of ChildrenNumber of Children Men Only Breast Lumps Erection Difficulties Lump in Testicles Penis Discharge Sore on Penis Other Muscle/Joint/Bone Arms Hips Back Legs Feet Neck Hands Shoulders Psychiatric Hyperventilation Insecurity Depression Trouble Sleeping Irritable Anxiousness Undecidedness Timid Hallucinations Loss of Memory Alcoholism Drug Addiction Drug Dependency Extreme Worry Sexual Problems Suicidal Thoughts Neurological Seizures Vertigo Dizziness Hand Trembling Loss of Sensations Loss of Facial Expression Weak Grip Paralysis Difficulty of Speech Tingling Loss of Memory Numbness Incoordination Integumentary Bruise Easy Hives Change in Moles Sores that won't heal Itching Unusual Swelling Sores/Ulcers Rash Scars Conditions AIDS Alcoholism Anemia Anorexia Appendicitis Asthma Bleeding Disordered Breast Lumps Bronchitis Breath Shortness Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herpes High Cholesterol HIV Positive Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Pneumonia Polio Prostate Problem Psychiatric Care Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Fever Ulcers Vaginal Infections Venereal Disease Other Medications - List Medications you are currently taking and dosages * Allergies to medications or substances * Wellness/Weight Loss Exam Form How much weight would you like to lose? * How did you hear about us? * History: (major surgeries, hospital stays, etc.) * Any Active Cancer? * Yes No Any Active Gall Bladder Disease? * Yes No Are You Pregnant? * Yes No Are You Breastfeeding? * Yes No Release of Information I hereby authorize SPINALAID to use, disclose, and/or release my protected health information to my insurance carriers) or other medical facilities to assist in my care, treatment, or payment of my medical claim. This information may be acquired in the course of my medical examination and/or treatment and may include drug use, alcoholism, and HIV positive test results. Patient Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
