Joint Pain New Patient Form

Please fill out the application entirely and legibly. We need all information for Insurance purposes.
**We will need to contact you both by phone & email.
Please be sure to give us the best phone number to reach you

Joint Pain New Patient Form

 +
What is your marital status *
Retired?

REVIEW OF SYMPTOMS

Please Check All That Apply *

PRESENT HEALTH CONDITIONS

In order of importance, list the health problems you are most interested in getting corrected. 🛈
+-
List approximately how long you have noticed these problems:
+-
Is there a certain time of day any of these problems are better or worse? *
Is your balance/walking ability affected? *
Check the things you have used for these problems
 

PRESENT HEALTH CONDITIONS

Name of all the doctors you have seen for these problems and treatment you received:
+-
Have your symptoms:
How would you describe the symptoms? Please check ALL that apply *
Is this condition interfering with any of the following?

SOCIAL HISTORY

Do you smoke? *
Do you drink? *
Do you exercise regularly? *
CURRENT PAIN LEVELS
How would you rate your pain in the last week? *
If you had to accept some level of pain after completion of treatment, what would be an acceptable level? *

ALLERGIES

List ALL allergies/sensitivities to medication, food, and other items here:
 AllergyReactions?
1
2
3
4

PRESCRIPTIONS

List the prescription drugs you are currently taking (or you may attach a list):
 NameDoseTimes Daily
1
2
3
4

OTHERS

List all nutritional supplements (vitamins, herbs, homeopathies, et c.) as above :
 NameDoseTimes Daily
1
2
3
4

Health History Form - Please Sign Below

PREVIOUS HEALTH CONDITION
PAIN POSSIBLE: This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied helath professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign
here indicating that we can release copies by your verbal request.
Please use your mouse to sign below
Signature *
clear