Patient Intake Form
Patient Intake Form
Fill out all sections below, then tap Send to provider.
🔒 Initials only — no personal info collected
Patient info
Initials only — no full name needed
Type of visit
New injury Old injury Car accident Workers compensation
Chief Complaint
Where does it hurt?
Spine
Neck Mid back Lower back
Upper body
Left shoulder Right shoulder Left elbow Right elbow Left wrist Right wrist Left hand Right hand
Lower body
Left hip Right hip Left knee Right knee Left ankle Right ankle Left foot Right foot
Jaw
Left TMJ Right TMJ
Does the pain radiate?
Yes No
Radiates to — spine
Neck Mid back Lower back
Upper body
Left shoulder Right shoulder Left elbow Right elbow Left wrist Right wrist Left hand Right hand
Lower body
Left hip Right hip Left knee Right knee Left ankle Right ankle Left foot Right foot
Jaw
Left TMJ Right TMJ
What caused it?
Woke up with it No idea Fall Prolonged sitting Prolonged standing Playing sports Exercising Golfing Basketball Yard work Mowing Gardening Other
When did symptoms start?
Today 1 day ago 1-3 days ago 4-7 days ago 1-2 weeks ago 3-4 weeks ago 1 month ago 2-3 months ago 4-6 months ago 6-12 months ago 1 year ago 1.5 years ago 2 years ago 3-5 years ago 5-10+ years ago
Pain scale (0-10)
5
Moderate
0 - None 5 - Moderate 10 - Severe
What does it feel like?
Dull Achy Sharp Stabbing Tight Stiffness Numbness & tingling Burning Pulling Dizziness
How often do you feel it?
Occasionally (0-25%) Off and on (26-49%) Most of the time (50-74%) Constant (75-100%)
Worst time of day
Morning Afternoon Evening After activity
Best time of day
Morning Afternoon Evening After activity
What makes it better?
Sitting Standing Sit to stand Lying down Resting Walking Running Looking up Looking down Looking left Looking right Forward bending Backward bending Rotating left Rotating right Exercise Weight lifting Sleeping Movement Not moving Ice Heat Biofreeze OTC meds Rx meds Brace Massage Driving Stretching Shoveling
What makes it worse?
Sitting Standing Sit to stand Lying down Resting Walking Running Looking up Looking down Looking left Looking right Forward bending Backward bending Rotating left Rotating right Exercise Weight lifting Sleeping Movement Not moving Ice Heat Biofreeze OTC meds Rx meds Brace Massage Driving Stretching Shoveling

Do you have a secondary complaint to add?