Intake Form

Please complete the following form and answer all questions before arriving for your appointment.

Be sure to include your insurance information. We'll see you soon!

First name (*)

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Middle Initial

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Last name (*)

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Date of Birth: Month (*)

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Day (*)

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Year (*)

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Phone Number (*)

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Secondary Phone Number

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Your Email Address (Responsible Party)

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Street Address (*)

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City (*)

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State (*)

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Zip-Code (*)

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Primary Insurance Carrier (*)

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Primary Insurance Member ID Number (*)

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Secondary Insurance Carrier

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Secondary Insurance Member ID Number

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Tertiary Insurance Carrier

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Tertiary Insurance Member ID Number

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Guarantor Information (if patient is not the cardholder) - Name, DOB, and relationship to patient

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Parent/Guardian Contact (if patient is a minor) - include name, relationship and phone number

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Preferred Local Pharmacy (*)

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Primary Care Physician (*)

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Emergency Contact - please include name, relationship and phone number (*)

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Past Surgeries (*)

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What medical problems do you have (ex. hypertension, diabetes, etc)?

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Marital Status (*)

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Are you employed? If so, what kind of work do you do? (*)

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What are you allergic to (please include reaction)? (*)

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What medications are you currently taking (please include dosage)? (*)

Please list all medications and include dosage

Do You Smoke (if so, how much)? (*)

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What health problems run in your family (ex. hypertension, diabetes, cancer)? Please specify who. (*)

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Pneumonia Shot in the past 5 years (please include year)? (*)

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Height (*)

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Weight (*)

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Shoe size (*)

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What specific problem brings you to our office today? (*)

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Where is the problem located? (example: heel, toe, bottom of foot) (*)

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How long has this been a problem for you? (*)

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How did the problem start? (*)

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Was this problem caused by an injury? (*)

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If yes, did that injury occur at work?

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If yes, have you filed or plan to file a claim for worker's compensation?

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How would you rate the pain on a 0-10 scale? (*)

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Describe the pain (aching, stabbing, sharp, shooting, etc.) (*)

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What makes the problem feel worse? (*)

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Does anything make the problem better? (example: ice, rest, medications, change shoes) (*)

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What treatments have you had previously for this problem? (*)

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Is there anything else we should know about the problem?

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For the below image uploads, please use png or jpg file format only, with a maximum file size of 5MB

Please Upload Picture of Your Driver's License (Front)

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Please Upload Picture of Your Insurance Card (Front)

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Please Upload Picture of Your Insurance Card (Back)

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Please Upload Picture of Your Secondary Insurance Card (Front)

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Please Upload Picture of Your Secondary Insurance Card (Back)

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