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New Patient Application

  
American Indian or Alaska Native  
Asian  
Black or African American  
White(Caucasian)  
Native Hawaiian or Pacific Islander  
I Decline to Answer  
  Male    Female
  
Hispanic or Latino  
Non Hispanic or Latino  
I Decline to Answer  

Health History

Do You

  
Yes   No  
How much and how long?
  
Yes   No  
How much and how long?
  
Yes   No  
How much and how long?
  
Yes   No  
How much and how long?
  
Yes   No  
How much and how long?
  
Yes   No  
How much and how long?

Yes   No  

Medications










Family History

Father



Mother



Current Health Condition

   Sudden (Date)
  
Gradual  
Continuing/Recurring
   Unknown  
Accident
(If auto fill out auto accident form as well)
  
None  
On/Off For Months  
Years  
  
Left   Right   Both  
  
No Change  
Improving  
Getting Worse  
  
Achy  
Burning  
Dull  
Sharp  
Stiff  
Throbbing  
Other  
  
Mild  
Moderate  
Severe  
  
  
Constant  
Frequent  
Intermittent  
Occasional  
Other  

What aggravates the pain?

What alleviates the pain?


  
Yes   No  
  

Previous Interventions

Height and Weight


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