Personal Information
- Full Name: _________________ Date: _________________
- Date of Birth: ______________ Age: ____ Gender: ______
- Address: ____________________________________________
- City: _________________ State: _____ ZIP: ____________
- Phone: (Home) _____________ (Mobile) ________________
- Email: ____________________________________________
- Emergency Contact: _____________ Phone: _____________
- Primary Care Physician: ______________________________
Insurance Information
- Insurance Provider: _________________________________
- Policy Number: ____________________________________
- Group Number: ____________________________________
- Policy Holder (if different): ___________________________
Current Health Condition
Primary Complaint
- Main reason for visit: ________________________________
- When did symptoms begin? ___________________________
- Pain intensity (1-10): ________________________________
- Character of pain: □ Sharp □ Dull □ Aching □ Burning
Medical History
- Previous injuries/surgeries: ___________________________
- Current medications: ________________________________
- Known allergies: ____________________________________
Health Habits
- Exercise frequency: _________________________________
- Occupation: _______________________________________
- Daily activities: ____________________________________
Consent for Treatment
I hereby authorize the doctors and staff at [Practice Name] to examine and treat my condition as deemed appropriate. I understand that I am responsible for all charges for services rendered.
Signature: _________________ Date: _________________
Office Policies
- 24-hour cancellation notice required
- Payment is due at time of service
- Please arrive 15 minutes before initial appointment
For Office Use Only
Reviewed by: _________________ Date: _________________