Clinical InformationPatient Name* First Last Email* Phone*Gender*MaleFemaleI prefer not to sayEmergency Contact Name* First Last Emergency Contact Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM DD YYYY Height*Weight*Please state the reason for your visit:Is your complaint due to an injury?*YesNoDate of injury* Date Format: MM slash DD slash YYYY Did the injury occur at work?YesNoWhat's the name of the employer?Was the injury from a motor vehicle collision?*YesNoPlease state how the injury occuredAllergies: Please list all medication, environmental, metal or jewelry allergiesDo you have any allergies?*NoYesAllergy #1Allergic Reaction #1Allergy #2Allergic Reaction #2Allergy #3Allergic Reaction #3Medications: Please list ALL current medicationsAre you currently taking any medications?*NoYesMedication #1Dose #1 (i.e. Take 1 capsule daily)Medication #2Dose #2 (i.e. Take 1 capsule daily)Medication #3Dose #3 (i.e. Take 1 capsule daily)Medication #4Dose #4 (i.e. Take 1 capsule daily)Medication #5Dose #5 (i.e. Take 1 capsule daily)Medication #6Dose #6 (i.e. Take 1 capsule daily)Hospitalizations or Surgeries: Please list any prior hospitalizations or surgeriesHave you had any prior hospitalizations or surgeries?*NoYesType of Surgery #1Date #1Location/Facility #1Type of Surgery #2Date #2Location/Facility #2Type of Surgery #3Date #3Location/Facility #3Family Medical History: Please list medical history for your immediate familyFamily MemberMotherMother Alive or Deceased?AliveDeceasedN/AMother Medical IllnessesFamily MemberFatherFather Alive or Deceased?AliveDeceasedN/AFather Medical IllnessesFamily MemberSibling(s)Sibling(s) Alive or Deceased?AliveDeceasedN/ASibling(s) Medical IllnessesCurrent Cigarette Smoker?*NoYesPacks per Day*# of Years*Past Cigarette Smoker?*NoYesQuit Date* MM DD YYYY # of Years*Vape User?*NoYesNicotine User?*NoYesHerbal User?*NoYesDo you drink alcohol?*NoYesHow often?*Have you been diagnosed with or treated for the following problems?Acid Reflux?*NoYesKidney Stones?*NoYesPulmonary Embolous?*NoYesEmphysema?*NoYesStomach Ulcer?*NoYesCoronary Artery Disease?*NoYesDiabetic?*NoYesWhat is your Hgb A1c?Cancer?*NoYesWhere is the cancer?Dialysis?*NoYesSleep Apnea?*NoYesUses CPAP?*NoYesCOPD?*NoYesHigh Blood Pressure?*NoYesHIV?*NoYesBlood clot in legs or arms?*NoYesCongestive Heart Failure?*NoYesHepatitis?*NoYesTuberculosis?*NoYesAsthma?*NoYesDiabetic Neuropathy?*NoYesChronic Kidney Disease?*NoYesHeart Attack?*NoYesThyroid Disease?*NoYesHigh Cholesterol?*NoYesAre you or is there a possibility you might be pregnant?*NoYesHow many weeks?Please list any other health conditions, not listed above:Patient Signature*Date* Date Format: MM slash DD slash YYYY Please do not fill out this section below as it is for authorized use only.Date reviewedDate reviewedDate reviewedPatient InitialPatient InitialPatient Initial