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Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Home
Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Initial Patient Intake Form
Full Name
Gender
Male
Female
Address
Birthdate
Phone Number
Alternate Phone Number
E-mail address
Occupation
Employer
Emergency Contact Name
Emergency Contact Phone Number
Who referred you to our office?
Current problem is result of:
Auto Accident
Work Accident
Slip & Fall
Major area(s) of complaint are
How did your problem begin?
Date problem began
Other doctors seen for this condition
Other treatments/tests you've had done for this condition
Have you been treated for any other health condition by a physician in the last year?
Yes
No
If yes, please explain
How often are symptoms present?
Constantly
Frequently
Occasionally
Intermittently
Describe your current symptoms (choose all that apply)
Sharp
Burning
Throbbing
Shooting
Tingling
Gripping
Dull
Numbness
Soreness
Aches
Weakness
Other_symptom
Other (please describe)
Since it began, your problem is:
Improving
Getting Worse
No Change
What makes the problem better? (choose all that apply)
Nothing
Lying Down
Standing
Walking
Sitting
Movement
Exercise
Inactivity/Rest
Other
Other (please describe)
What makes the problem worse? (choose all that apply)
Nothing
Lying Down
Standing
Walking
Sitting
Movement
Exercise
Inactivity/Rest
Other
Other (please describe)
List all allergies
List all medications you are presently taking (including vitamins & supplements):
List any surgeries, fractures, serious illnesses or hospitalizations
List any car accidents
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