Date
I was referred by How did you hear about the clinic?
Primary Insurance Information:
Secondary Insurance Information:
Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptom has been present:
Describe your injury and pain: Pain level on scale of 1-10 (10 is excruciating pain)
Are you exposed to 2nd hand smoke?
How many drinks currently per week? (1 drink=5 oz. wine, 12 oz. beer, and/or 1.5 oz. spirits)
I am allergic to the following medications:
I am allergic to the following foods or supplements:
Please list your symptoms/reactions to the above medications and/or foods:
Medications: Please list any medications that you are currently taking or have taken in the last month, including antibiotics, non-prescription drugs, and prescription drugs.
Supplements: List all vitamins, minerals, and other nutritional supplements that you are currently taking.
Have you ever had any of the following Illnesses?
Check the box if yes and provide number.
Menstrual History:
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