If you have scheduled an appointment with us and you are new to our office, please fill out the form below prior to your visit. Please enable JavaScript in your browser to complete this form.Name *FirstLastNickname or Preferred NameAddress *City *State *Zip *Phone *EmailOccupationEmployerDate of Birth *Social Security NumberNote: if not provided, you will be expected to provide payment in full prior to each visit and cannot carry a balance with us.Marital StatusSingleMarriedDivorcedSeparatedWidowedPreferred Language *EnglishSpanishIndianJapaneseChineseKoreanFrenchRussianGermanOtherRaceWhiteAmerican Indian or Alaska NativeNative Hawaiian/Pacific IslanderBlack or African AmericanHispanic or LatinoDecline to AnswerOtherEthnicityHispanic or LatinoNot Hispanic or LatinoDecline to AnswerAre you seeing another healthcare provider for other health problems or conditions? If yes, please list the problem(s), date(s) began, and treating provider:Have you been diagnosed with:HypertensionDiabetes Type IDiabetes Type IICurrent drugs (prescription and non-prescription), including dosage and frequency: *Allergies (include type of allergy and reaction): *Past surgeries and approximate dates:Family history of: *ArthritisCancerDiabetesHeart DiseaseBack problemsScoliosisNoneSmoking status: *NeverPast SmokerCurrent SmokerPrefer not to sayAlcohol consumption: *NoneCasualModerateHeavyPrefer not to sayCaffeine consumption: *NoneLess than 3 drinks per day3-6 drinks per dayMore than 6 drinks per dayPrefer not to sayNon-medical drug use: *NoneRecreational userAddictionPrefer not to sayExercise: *NeverDailyWeeklyOccasionallyAre you wearing:Heel liftsArch supportsFoot orthoticsMajor complaint(s): *How and when did the condition begin?Other doctors seen:Is it getting worse?YesNoHave you lost work/school days?YesNoHave you had a similar condition before?YesNoIf you have had a similiar condition before, when?Is this injury related to:Work accidentAuto accidentOther accidentPlease indicate whether the below conditions have applied to you in the past or present. Any that have never applied, leave blank.OKFractured bonesPast Present Auto accidentPast Present Other accidents/fallsPast Present Knocked unconsciousPast Present Back curvaturePast Present Mental/emotional disordersPast Present ArthritisPast Present DiabetesPast Present Swollen/painful jointPast Present Convulsions/epilepsyPast Present Skin ProblemsPast Present ItchingPast Present Bruise easilyPast Present CancerPast Present Frequent Colds/FluPast Present Ringing in earsPast Present Hearing lossPast Present FaintingPast Present Loss of balancePast Present Blurred or double visionPastPresentUpper back pain or stiffnessPastPresentMid back pain or stiffnessPastPresentLow back pain or stiffnessPastPresentNumbness/tingling/pain in buttocks, legs, feet or toesPastPresentKnee painPastPresentPain with cough, sneeze, or strain at stoolsPastPresentHip painPastPresentFoot troublePastPresentNervousPastPresentTensionPastPresentDepressedPastPresentIrritablePastPresentAnemiaPastPresentExcess sweatingPastPresentTremorsPastPresentLight bothers eyesPastPresentLight headed upon risingPastPresentAllergyPastPresentSinus problemsPastPresentUnder stressPastPresentCrave sweets or saltPastPresentEating disordersPastPresentTrouble sleepingPastPresentTrouble concentratingPastPresentLoss of memoryPastPresentLearning disabilityPastPresentChest painPastPresentAsthmaPastPresentLung problemsPastPresentDifficult breathingPastPresentWheezingPastPresentHeart problemsPastPresentHigh or low blood pressurePastPresentStrokePastPresentVaricose veinsPastPresentLiver troublePastPresentGall bladder troublePastPresentDigestive problemsPastPresentExcessive gasPastPresentBelching/bloating after mealsPastPresentHeartburnPastPresentUlcersPastPresentDiarrheaPastPresentColon troublePastPresentHemorrhoidsPastPresentMistake sidednessPastPresentStutterPastPresentDyslexiaPastPresentMood changesPastPresentLose temper easilyPastPresentHeadachePastPresentNeck pain or stiffnessPastPresentNumbness/tingling/pain in arms, hands, or fingersPastPresentJaw pain or click (TMJ)PastPresentHead seems too heavyPastPresentHead/shoulders tiredPastPresentDifficulty in excessive standing, walking, sitting, lifting, household duties, etc)PastPresentShoulder painPastPresentDizzinessPastPresentProstate problemsPastPresentImpotencePastPresentKidney troublePastPresentKidney stonesPastPresentFrequent urinationPastPresentBreast lumps, soreness, dischargePastPresentDischargePastPresentMenstrual problems/PMSPastPresentPainful urinationPastPresentMenopausal problemsPastPresentPregnancy (NOW)PresentBedwettingPastPresentEar infectionsPastPresentHepatitisPastPresentVenereal diseasePastPresentAIDS/ARCPastPresentAt times we may need to contact you by to discuss an appointment, health information, or financial information. In order to protect your privacy, we need to know how you would like to be contacted by our office staff or doctors.OKHome phoneCell phoneCell carrier (required if you wish to receive appointment reminder texts)Work phoneEmail addressPreferred Contact method *Home phoneCell phoneWork phoneEmailPlease list below any individuals you would like us to be able to share information with and the individual's relationship to the patient. Please also specify any restrictions to the information shared with each person. If you do not want us to be able to share information with anyone, please enter "no one." *Please note that if no one is listed here, we will not share any information with any individuals other than the patient, regardless of personal relationship to the patient.Expiration dateNo expiration (unless revoked or terminated by the patient or the patient’s personal representative)Expiration date listed below:Authorization expires on:EmailSubmit
