PATIENT INTAKE
Patient Name:
Date:
Last Name First Name
Date of Birth:
Phone:
Home Work Cell
Please indicate pain location
List OTHER complaints, how long have been having them, what treatment has been given?
Address:
City State Zip
Occupation:
SSN:
Major Complaint:
When did you first notice the problem?
What diagnostic studies have been done?
What treatment (medication etc.) has been given? When? What results?
1.
2.
3.
List surgeries you had in the past and when you had them:
List allergies you have (food, environmental and medication):
Circle diseases you have and indicate how long you have had it:
Diabetes ______ Hypertension______ Heart disease______ Liver disease______
Arthritis______ Kidney disease______ Lung disease______ High Cholesterol ______
Are you often exposed to chemicals and toxic materials? (oil painting, pesticides, etc) _____
If yes, what are they?
Do you have amalgam (silver) filling in your teeth? _____ If yes, how many? ______
Contact E-Mail: