Intake Form Patient Intake Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Sex * MaleFemale Marital Status * SingleMarriedOther Student * Full-TimePart-TimeN/A Are You Employed? * YesNo Emergency Contact Information Primary Insurance Information Secondary Insurance Information Injury Information How and Where Injury Occured (Describe in detail) * Current Injury Related To: * Workers CompAuto AccidentSlip/FallN/A Did you file an Injury Report? * YesNo (Skip to next section) Medical Providers Medical Information Current Physical Health * GoodFairPoor For Women: Currently Pregnant? YesNo Do You Smoke or Use Tobacco? * YesNo Do You Take Medication or Herbal Supplements * YesNo If Yes, List Medication/Herbal Supplement & Dosage. Health History Do you have or had any of the following medical conditions? (Check all that apply) * Abnormal BleedingAlcohol/Drug AbuseAnemiaArthritisArtificial Bones/Joints/ValvesAsthmaCancer/ChemotherapyColitisCongenital Heart DefectDiabetesDifficulty BreathingEmphysemaEpilepsy/SeizureFainting SpellsFrequent HeadachesGlaucomaHay FeverHeart AttackHeart MurmurHeart SurgeryHemophiliaHepatitisHigh Blood PressureHIV+/AIDSHospitalized for any reasonKidney ProblemsLiver DiseaseLow Blood PressureLupusLyme DiseaseMitral Valve ProlapseMononucleosis Osteoporosis PacemakerPsychiatric ProblemsRadiation TreatmentShinglesSickle Cell Disease/TraitStrokeThyroid ProblemsTuberculosis (TB)VertigoNone List Other Medical Conditions You Have or Had Please double-check your entries before submitting form. By clicking "Submit" button, you acknowledge that all the information you provided are true.