Muscle Nerve Spine Care and Elderly House Calls
New Patient Intake Form
New Patient Name
New Patient Name
Referring physician (If applicable) Name & Phone:
Reason for referral/Reason for your visit:
Please check any of the following whose care you are under:
If you have seen any of the above during the past three months, please describe for what reason (illness, medical condition, routine physical, etc.):
Date of injury or when symptoms began:
Is this injury or symptom related to any of the following:
Briefly describe your injury/symptoms:
Did you have surgery for the above injury or symptoms?
Are you presently taking any medication? If yes, please list name, for what condition, and how long.
List any medications you are allergic to:
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?
High blood pressure
Drug or alcohol addiction
Other arthritic 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?
Inflammatory arthritis (rheumatoid, ankylosing)
Chemical dependency (i.e., alcoholism)
During the past month, have you been bothered by having little interest or pleasure in doing things?
Please list all surgeries or other conditions for which you have been hospitalized, including the approximate date and reason for surgery or hospitalization:
Please describe all significant injuries for which you have been treated (including fractures, dislocations, sprains/strains) and the approximate date of injury:
How many packs of cigarettes do you smoke a day?
How many days per week do you drink alcohol? Do do you drink in an average sitting? (If one drink equals one beer or glass of wine.)
Please check any of the below that you have experienced in the last 12 months:
Nausea and/or vomiting
Numbness or tingling
Loss of vision
Blood in stool
Blood in urine
Stress at home or work
Is there anything else about either your history or your current condition that you feel is important to mention?