Patient Intake Form - Auto injury, Physical therapy, Back pain get Chiropractic care in Salt Lake City area in Millcreek, Holladay Utah.

Patient Intake Form - Auto injury, Physical therapy, Back pain get Chiropractic care in Salt Lake City area in Millcreek, Holladay Utah.

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Patient Intake Form

Last Name: First Name: Middle Initial: Address: City: State: Country: Zip: Home Phone: Work Phone: Occupation: Employer: SS#: Date of Birth: Insurance Co. Name:	Emergency Contact: Referrer By: Patient Symptoms Describe in detail the reason for your visit: When did the problem start?: A car accident or on the job injury : List Medications Used: Who has treated or evaluated this problem in the past?

If 0% represents no pain, and 100% represents unbearable pain, please rate your pain by selecting when your pain is: At its worst, At its best, and Most of the time… At its worst: At its best: Most of the time: What makes it better: What makes it worse: Social & Employment History Marital Status: Current Employment: Full Time Part Time Job Duties / Activity Required: Tobacco: Yes None Alcohol: Yes None Medical Allergies List any allergies and associated symptoms:	Medical History & ROS For a current medical problem or a symptom you are currently experiencing. Please identify family members with these problems or those with similar symptoms. Any family history of serious illness or disease (i.e. cancer, heart disease, stroke, etc…) Problem(s): No Family History or Current Family Medical Problems: None Please check any of the following problems you currently or previously experienced. Previous surgeries including dates Previous auto accidents, please include dates and details Previous Falls/ Injuries, please include dates and details Security Code: * Reload Image

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