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Patient Intake Form
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Do you currently smoke tobacco of any kind?

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If yes, how often do you smoke:

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If yes, what is your level of interest in quitting smoking?

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Current medications, including dosage if known.

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List any known allergies you have had to any medications.

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Briefly list your main health problems:

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Has any doctor diagnosed you with Hypertension presently?

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If yes, describe:

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Are you pregnant?

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Has any doctor diagnosed you with Diabetes presently?

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If yes, what kind?

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If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%?

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Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days?

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What brings you to our office today?

Primary complaint:

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Did it begin:

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Date of first symptoms:

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What relieves the symptoms?

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What makes the symptoms increase?

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Type of Pain:

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Does the pain radiate into your:

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Do you have numbness or tingling?

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How often do you feel these symptoms?

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Please rate the intensity of your symptoms on a scale of 1-10 (1 = no symptoms, 10 = extreme):

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Please list all previous treatments for this condition (give doctor’s name and dates, if possible):

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Do you have any family members who suffer from the same complaint? If so, who?

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Secondary complaint:

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Did it begin:

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Date of first symptoms:

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What relieves the symptoms?

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What makes the symptoms increase?

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Type of Pain:

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Does the pain radiate into your:

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Do you have numbness or tingling?

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How often do you feel these symptoms?

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Please rate the intensity of your symptoms on a scale of 1-10 (1 = no symptoms, 10 = extreme):

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Please list all previous treatments for this condition (give doctor’s name and dates, if possible):

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Do you have any family members who suffer from the same complaint? If so, who?

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Surgeries:

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Hospitalizations:

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Accidents (car, work or home):

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Trauma (falls, broken bones, etc.):

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Serious Illness:

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Please check if you have had any of the following:

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