Need Help? Call:
541-441-1224
Need Help? Call:
541-441-1224
Clinical Intake
Profile
Medical
Insurance
Conditions
Personal Info
First Name *
Last Name *
Date of Birth *
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Gender *
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Address *
City *
Country
Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
------------
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
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
Medical Info
Primary Complaint
General Health
Source of Referral
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
Adjuster's Name
Policy Number
Office Address
City
Country
Prov / State
Postal Code / Zip
Phone
Fax
Email Address
Claims / Benefits
Conditions
Area of Complaint
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Comments
Left Side of Neck
Left Side of Low Back
Left Side of Mid Back
Left Side of Upper Back
Left Shoulder
Left Arm
Left Hand
Left Hip
Left Knee
Left Ankle
Left Foot
Left Leg
Right Leg
Right Side of Upper Back
Right Foot
Right Ankle
Right Knee
Right Side of Neck
Right Side of Low Back
Right Side of Mid Back
Right Shoulder
Right Arm
Right Hand
Right Hip
Right Elbow
Left Elbow
Right Wrist
Left Wrist
Chest
Abdomen
Headaches
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Comments
Migraines
Headaches
Cluster
Rebound
Sinus
Chronic Daily Headache
Tension
Family History
Arthritis
Cardiovascular
Respiratory
Comments
Arthritis
Cardiovascular
Respiratory
Blood
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Comments
Hepatitis
HIV
Haemophilia
Thrombosis/Embolism
Anemia
Bleeding Disorder
HIV/AIDS
Hypercoagulability
Polycythemia
High Cholesterol
Cardiovascular
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Comments
High Blood Pressure
Low Blood Pressure
Congestive Heart Failure
Heart Attack
Phlebitis
Cardiovascular Accident
Pacemaker
Heart Disease
Cardiovascular Conditions
Myocardial infarction
Varicose Veins
Blood Clots
Lymphedema
Cold Hands
Cold Feet
Acute Coronary Syndrome
Aneurysm
Angina
Atherosclerosis
Cardiac Arrhythmia
Chronic Ischemic Heart Disease
Chronic Venous Insufficiency
Congenital Heart Defect
Coronary Artery Disease
Hyperlipidemia
Pericarditis
Raynaud Disease
Rheumatic Heart Disease
Valve Disorders
Blood Pressure
Endocrine
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Comments
Diabetes
Acute Pancreatitis
Hyperthyroidism
Hypothyroidism
Pituitary and Growth Disorder
Prostate Condition
Gastrointestinal
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Comments
Digestive Conditions
Crohn's Disease
Celiac Disease
Constipation
Diarrhea
Diverticulitis
Eating Disorder
Esophageal Disorder
Fecal Impaction
Intestinal Polyps
Irritable Bowel Syndrome
Poor Appetite
Stomach Disorder
Ulcerative Colitis
Hearing
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Comments
Ear Problems
Hearing Loss
Conductive Hearing Loss
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Immune
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Comments
Allergies
Cancer
Lupus
Rheumatoid Arthritis
Anaphylaxis
Hodgkin Lymphoma
Infectious Mononucleosis
Leukemia
Non-Hodgkin Lymphoma
Kidney
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Comments
Bladder Disorder
Chronic Kidney Disease
Congenital Kidney Disease
Electrolyte Imbalance
Kidney Stones
Renal Cysts
Urinary Incontinence
Urinary Tract Infection
Musculoskeletal
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Comments
Arthritis
Osteoporosis
Artificial Joints / Special Equipment
Sinus Problems
Fibromyalgia
Gout
Jaw Pain (TMJD)
Osteoarthritis
Ankylosing Spondylitis
Bone Disease
Compartment Syndrome
Dislocation
Fracture
Hereditary/Congenital Deformity
Joint Injury
Osgood-Schlatter Disease
Osteomalacia
Paget Disease
Psoriatic Arthritis
Scleroderma
Scoliosis
Strain/Sprain
Amyotrophic Lateral Sclerosis (ALS)
Muscular Dystrophy
Myasthenia Gravis
Tendonitis/Bursitis
Neurological
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Comments
Stroke
Loss of Sensation
Epilepsy
Cerebral-vascular Accident
Shingles
Dizziness
Cerebral Palsy
Parkinsons
Herniated Disc
Multiple Sclerosis
Numbness
Burning
Tingling
Stabbing
Vertebral and Spinal Cord Injury
Huntington Disease
Brain Disorder
Chronic Pain Disorder
Brain Injury
Cerebral Vascular Accident (Stroke)
Seizure Disorder
Transient Ischemic Attacks (TIA)
Sciatic Pain
Reproductive
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Comments
Pregnancy
Gynaecological Conditions
Breast Disorder
Ectopic Pregnancy
Endometriosis
Menopause
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pelvic Inflammatory Disease
Premenstrual Syndrome
Uterine Disorder
Respiratory
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Comments
Chronic Cough
Shortness of Breath
Asthma
Emphysema
Bronchitis
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
COPD
Cystic Fibrosis
Tuberculosis
Skin
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Comments
Skin Conditions
Skin Irritations
Infectious Skin Conditions
Herpes
Hypersensitive Reaction
Athlete's Foot
Melanoma
Bruise Easily
Acne
Allergic Dermatosis
Athletes Foot
Chemical Burn
Hypersensitive Reactions
Melanoma/Carcinoma
Pigmentary Disorder
Plantar's Wart
Psoriasis
Rash
Rosacea
UV Burn
Miscellaneous
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Comments
Vision Problems
Vision Loss
Mental Health Issues
Surgical Pins or Wire
Other Diagnosed Diseases
Insomnia
Other Medical Conditions
Submit Intake
×