Reason for Visit
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
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Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
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Birth Day
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Birth Year
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Gender
Male
Female
Reason for Visit
* Required Information
Chief Complaint
*
What is the reason for your visit? (For example: right knee pain, left foot pain, etc.)
*
Was this the result of an injury?
yes
no
*
What was the date of your injury?
*
Please describe how you were injured:
*
Please explain how and when your symptoms began:
*
Have you seen another provider for this condition or injury? If yes, what type of doctor did you see?
ER
Physical Therapist
Neurosurgeon
Orthopedic
Primary Care Physician
Chiropractor
Other
No, I have not seen another provider for this injury
Please list other providers:
*
Have you had any of the following for this problem?
bone scan
MRI
x-rays
CT scan
injection(s)
physical therapy
medication
surgery
other testing
No previous treatment or studies
*
Have you had 2 or more falls in the past year or any fall with an injury in the past year?
yes
no
Pain Information
*
Pain frequency:
intermittent
continuous
*
Pain status:
improving
worsening
unchanged
*
Current severity of pain on a scale of 1-10
0
1
2
3
4
5
6
7
8
9
10
(0= no pain, 1 = less painful, 10 = more painful)
Current Symptoms
Please select the symptoms you are currently experiencing.
*
General Health
chills
difficulty sleeping
fever
weight decrease
weight increase
None
*
Blood
bleeding tendency
easy bruising
hemophilia
swollen lymph nodes
None
*
Eye
blurred vision
double vision
visual disturbances
vision loss
None
*
Ears, Nose & Throat
hearing problems
nose bleeds
oral ulcer
sleep apnea
vertigo
None
*
Endocrine
diabetes
weight change
None
*
Gastrointestinal
constipation
diarrhea
heartburn
nausea
vomiting
None
*
Lungs
chest tightness
shortness of breath
wheezing
None
*
Heart
heart disease
pacemaker
shortness of breath on exertion
None
*
Kidney & Bladder
blood in urine
frequent urination
incontinence
None
*
Muscle, Bone & Joints
arthritis
back pain
decreased range of motion
gout
joint pain
joint swelling
loss of strength
muscle cramp
muscle pain
muscle twitch
muscle weakness
stiffness
swelling
None
*
Nervous System
dizziness
headaches
incoordination
numbness
paralysis
seizures
tingling sensations
tremor
None
*
Mental Health
anxiety
confusion
depression
mood swings
panic attacks
sleep problems
None
*
Skin
rash
redness
None
*
Allergy / Immune
hay fever
HIV exposure
hives
seasonal allergies
None
Other Symptoms
If you have other symptoms not listed above, please explain here:
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 468
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.