Patient Information (Full Legal Name)
What is your height?

What is the reason for today’s visit?

Is your visit related to an accident / injury?
Where did the accident / injury occur?

Date of onset:

How long have you experienced the problem that has brought you to our office?
# of weeks
# of months
# of years

Current severity of symptom(s) on a scale of 0 – 10 (0 = least painful 10 = most painful)


Please list all medications you are currently taking.

Pharmacy name, address and phone number:

Are you currently taking any diet pills or have taken them in the past?

Have you taken any type of blood thinners (Baby Aspirin, Coumadin, Plavix, Pradaxa, Vitamin E, etc.)?
Drug name
How long
Date stopped


Other Allergies:


Preferred language
Other Languages:

Previous Treatments and Tests

Have you had any of the following treatments or tests for this problem?
Other Treatments:

Where and when did you have the test(s) or treatment(s)?

Have you had surgery related to today’s visit?
Date and type of surgery:

For your current condition, have you tried the following?
Physical Therapy
How Long?
How Long?
Cervical Traction
How Long?
How Long?
Epidural Blocks
How Long?
Bed Rest
How Long?

List all doctors that you currently see:

Social History

What is your occupation?

What is your marital status?

Please describe your cigarette smoking status.
How many packs per day?

Counseled to quit smoking?

Do you drink alcohol?
How many drinks per week?

How often do you exercise?

Medical History

Do you have any past medical history?
Other Medical:

Family Medical History

Do you have any family medical history?

Review of Symptoms





Ear, Nose, and Throat







Are you experiencing any bowel changes regarding your visit today?


Are you experiencing any bladder changes regarding your visit today?







Surgical History

Do you have any surgical history?
Heart Surgery
Spinal Fusion
Other Surgeries:

Do you have any implants?
Other Implants:

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 443
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.