"*" indicates required fields Clinical InformationPatient Name* First Last Date of Birth* Month Day Year Gender*MaleFemaleI prefer not to sayHeight* Weight* Email* Patient Phone*Emergency Contact Name* First Last Emergency Contact Phone Number*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please state the reason for your visit: Upload Photo IdentificationAccepted file types: jpg, gif, png, pdf, tiff, doc, docx, , Max. file size: 8 MB.Injury DetailsIs your complaint due to an injury?*YesNoDate of injury* MM slash DD slash YYYY Was the injury from a motor vehicle collision?*YesNoDid the injury occur at work?YesNoWhat's the name of the employer? Please state how the injury occuredAllergies: Please list all medication, environmental, metal or jewelry allergiesDo you have any allergies?*NoYesAllergy #1 Allergic Reaction #1 Allergy #2 Allergic Reaction #2 Allergy #3 Allergic Reaction #3 Medications: Please list ALL current medicationsAre you currently taking any medications?*NoYesMedication #1 Dose #1 (i.e. Take 1 capsule daily) Medication #2 Dose #2 (i.e. Take 1 capsule daily) Medication #3 Dose #3 (i.e. Take 1 capsule daily) Medication #4 Dose #4 (i.e. Take 1 capsule daily) Medication #5 Dose #5 (i.e. Take 1 capsule daily) Medication #6 Dose #6 (i.e. Take 1 capsule daily) Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeriesHave you had any prior hospitalizations or surgeries?*NoYesType of Surgery #1 Date #1 Location/Facility #1 Type of Surgery #2 Date #2 Location/Facility #2 Type of Surgery #3 Date #3 Location/Facility #3 Family Medical History: Please list medical history for your immediate familyFamily MemberMotherMother Alive or Deceased?AliveDeceasedN/AMother Medical Illnesses Family MemberFatherFather Alive or Deceased?AliveDeceasedN/AFather Medical Illnesses Family MemberSibling(s)Sibling(s) Alive or Deceased?AliveDeceasedN/ASibling(s) Medical Illnesses Habit DetailsCurrent Cigarette Smoker?*NoYesPacks per Day* # of Years* Past Cigarette Smoker?*NoYesQuit Date* Month Day Year # of Years* Vape User?*NoYesNicotine User?*NoYesHerbal User?*NoYesDo you drink alcohol?*NoYesHow often?* Have you been diagnosed with or treated for the following problems?Acid Reflux?*NoYesKidney Stones?*NoYesPulmonary Embolous?*NoYesEmphysema?*NoYesStomach Ulcer?*NoYesCoronary Artery Disease?*NoYesDiabetic?*NoYesWhat is your Hgb A1c? Cancer?*NoYesWhere is the cancer? Sleep Apnea?*NoYesDialysis?*NoYesUses CPAP?*NoYesCOPD?*NoYesHigh Blood Pressure?*NoYesHIV?*NoYesBlood clot in legs or arms?*NoYesCongestive Heart Failure?*NoYesHepatitis?*NoYesTuberculosis?*NoYesAsthma?*NoYesDiabetic Neuropathy?*NoYesChronic Kidney Disease?*NoYesHeart Attack?*NoYesThyroid Disease?*NoYesHigh Cholesterol?*NoYesAre you or is there a possibility you might be pregnant?*NoYesHow many weeks? Do you take anticoagulants?*NoYesReason: Duration of care: Please list any other health conditions, not listed above: Patient Signature*Date* MM slash DD slash YYYY