New Patient Intake Form

New Patient Name *
New Patient Name
Please check any of the following whose care you are under:
Is this injury or symptom related to any of the following:
Did you have surgery for the above injury or symptoms?
Have you ever taken steroid medications for any reason?
Do you have a pacemaker?
Are you currently pregnant or think you might be pregnant?
Have you ever been diagnosed as having any of the following conditions?
During the past month, have you been feeling down, depressed, or hopeless?
Please check if anyone in your immediate family (parents, brothers, sisters) have ever been treated for any of the following?
During the past month, have you been bothered by having little interest or pleasure in doing things?
Please check any of the below that you have experienced in the last 12 months: