Patient Information
(Full Name as shown on your insurance card)
 
 
 
 
 
 
 
 
 
 
 
 
* Required Information
 

Chief Complaint

*What is the reason for your visit? (For example: right knee pain, left foot pain, etc.)
*Was this the result of an injury?
 
 
*What was the date of your injury?
*Please describe how you were injured:
*Please explain how and when your symptoms began:
*Have you seen another provider for this condition or injury? If yes, what type of doctor did you see?
 
 
 
 
 
 
 
 
 
 
Please list other providers:
 
*Have you had any of the following for this problem?
 
 
 
 
 
 
 
 
 
 
 
 
*Have you had 2 or more falls in the past year or any fall with an injury in the past year?
 
 
 

Pain Information

*Pain frequency:
 
 
*Pain status:
 
 
 
*Current severity of pain on a scale of 1-10
(0= no pain, 1 = less painful, 10 = more painful)
 

Current Symptoms

 

Please select the symptoms you are currently experiencing.

*General Health
 
 
 
 
 
 
 
*Blood
 
 
 
 
 
 
*Eye
 
 
 
 
 
 
*Ears, Nose & Throat
 
 
 
 
 
 
 
*Endocrine
 
 
 
 
*Gastrointestinal
 
 
 
 
 
 
 
*Lungs
 
 
 
 
 
*Heart
 
 
 
 
 
*Kidney & Bladder
 
 
 
 
 
*Muscle, Bone & Joints
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Nervous System
 
 
 
 
 
 
 
 
 
 
*Mental Health
 
 
 
 
 
 
 
 
*Skin
 
 
 
 
*Allergy / Immune
 
 
 
 
 
 

Other Symptoms

If you have other symptoms not listed above, please explain here:
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 468
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.