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New Patient Intake Form

    Date

    Referred by

    Name

    Date of birth

    Age

    Height

    Weight

    Occupation

    Telephone: Home

    Work

    Home address:

    Email address:

    EMERGENCY CONTACT: In case of an emergency, please contact: Name:

    Phone #

    Relationship

    Primary Physician:

    Phone #

    Chief complaint:

    How long have you had this health concern?

    What makes your health concern worse? (exercising, certain movements, heat, cold etc.)

    What makes your condition better? (rest, heat, ice, etc.)

    What other forms of treatment have you sought for this condition, when did you have these treatments, and were they helpful?

    Please describe the condition in detail:

    Please indicate if you have any significant illnesses:CancerDiabetesHepatitisHerpesHerniaHeart DiseaseHypertensionSeizures/EpilepsyStrokeArteriosclerosisVaricose veinsSleep apneaAsthmaHIVBlood clotting disorderEmotional DisordersInfectious DiseasesTuberculosisOsteoporosisSexually Transmitted Diseases

    Other:

    Any Drug allergies?YesNo

    If Yes, please explain:

    Do you follow any diet?

    Alcohol IntakeYesNo

    How Much?


    List any medications and supplements you are currently taking: (Continue on back if necessary.)

    Medicine

    Dosage

    Reason

    How Long

    Prescribed by

    Supplements:

    The information on this form is correct and accurate to the best of my knowledge

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