Intake Form 2021
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
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Gender
Male
Female
Identify as
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Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
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Policy Number
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Claims / Benefit
Conditions
TMJ (Jaw)
Clenching
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Ear Ringing
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Difficulty Opening Jaw
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Jaw Pain
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Clicking
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Locking
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Difficulty Chewing
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you tested positive for COVID-19?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Vocal Health
Hoarseness
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Complete Loss of Voice
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Difficulty Swallowing
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Pain
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Whiplash
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Vocal History
Vocal Injury
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Mid Back
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Right Side of Mid Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Headaches
Sinus
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Migraines
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Chronic Daily Headache
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Headaches
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Tension
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Rebound
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Other Headaches
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Respiratory
Chronic Cough
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Shortness of Breath
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Asthma
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Emphysema
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Bronchitis
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Tuberculosis
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Other Respiratory
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Musculoskeletal
Tendonitis/Bursitis
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Osteoporosis
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Artificial Joints / Special Equipment
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Whiplash
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Dislocation
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Osteoarthritis
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Fracture
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Joint Injury
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Scoliosis
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Arthritis
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Strain/Sprain
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Fibromyalgia
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Other Musculoskeletal
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Blood
Thrombosis/Embolism
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Anemia
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HIV/AIDS
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Hepatitis
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Other Blood
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Cardiovascular
Heart Attack
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Phlebitis
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Cardiovascular Conditions
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Pacemaker
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Cardiovascular Accident
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Heart Disease
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Varicose Veins
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Raynaud Disease
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High Blood Pressure
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Stroke
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Low Blood Pressure
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Blood Clots
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Congestive Heart Failure
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Other Cardiovascular
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Neurological
Brain Disorder
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Herniated Disc
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Brain Injury
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Stroke
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Transient Ischemic Attacks (TIA)
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Loss of Sensation
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Sciatic Pain
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Shingles
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Tingling
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Cerebral-vascular Accident
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Dizziness
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Other Neurological
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Immune
Anaphylaxis
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Lupus
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Rheumatoid Arthritis
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Allergies
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Cancer
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Other Immune
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Family History
Arthritis
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Cardiovascular
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Respiratory
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Kidney
Urinary Tract Infection
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Other Kidney
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Gastrointestinal
Crohn's Disease
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Celiac Disease
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Irritable Bowel Syndrome
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Digestive Conditions
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Other Gastrointestinal
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Hearing
Ear Problems
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Tinnitus
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Hearing Loss
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Vertigo
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Other Hearing
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Skin
Hypersensitive Reactions
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Melanoma/Carcinoma
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Skin Conditions
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Plantar's Wart
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Herpes
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Bruise Easily
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Psoriasis
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Rash
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Endocrine
Hyperthyroidism
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Diabetes
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Hypothyroidism
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Other Endocrine
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Reproductive
Gynaecological Conditions
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Other Reproductive
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Miscellaneous
Surgical Pins or Wire
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Vision Problems
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Vision Loss
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Other prenatal concerns
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Due Date
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Edema/Swelling
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Carpal Tunnel Syndrome
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High Risk Pregnancy
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Emotion / Mood
Rate the stress in your life (1-10)
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