Primary Care Physician
First Name
Last Name
Middle:
Is this your legal name?
If not, what is your legal name?
(Former name):
Salutation
Marital status (checkone)
Birthday
Age:
Sex
PO Box /Street Address
City
State
Zip Code
Cell phone
Home Phone
Social Security Number:
Occupation:
Employer
Employer Phone Number:
Chose clinic because / Referred to clinic by (please check one)
Email
Spouse’s Name
Please List any other family members/friendsinvolved in your health decisions
Insurance Name
Insurance Type
Name of local friend or relative (not living at same address)
Patient/Guardian signature:
Date Signed
What is your major complaint?
How long have you had this problem?
Before you began having this problem was there an earlier condition, accident, or injury that could have brought this problem about?If so please describe:
What have you tried for treatment that did not work?
Have you seen a M.D., P.T., or a D.C. for this problem?
How does this problem interfere with your daily day life?
Have you been worried about getting this problem resolved?If yes, please describe
What is your main concern about your symptoms?
On a scale from 1 to 10 (with 10 being the highest), what is your interest in getting help for the problem?
Please list all of your medications to review witht the doctor
Height:
Weight: