Intake Form - Move Well MD

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Home
Services
Providers
Blog
About
Contact
Patient Intake Form

Home
Services
Providers
Blog
About
Contact
Patient Intake Form

Patient intake form

Patient Information

First Name

Last Name

Date of Birth

Cell

Gender

Male Female Other

Age

Ethnicity

Social Security#

Marital Status

Single Married Widowed Divorced

Address (please include Apt number if any)

City

State

Zip Code

Insurance Company

ID#

Group#

Where / Who did you hear about us from? (from menu)

Occupation

Employer

Emergency Contact’s Name:

Emergency Contact's Phone:

Patient Condition

Reason for visit

When did your symptoms first appear?

Are your symptoms the result of an accident or fall?

Yes No

Are your symptoms getting worse?

Yes No Unsure

Your symptoms are:

Constant Intermittent Worse in the AM Worse in the PM

Please indicate the quality of your pain:

Sharp Numbness Weakness Headache Dull/ Achy Burning Stiffness Blurry Vision Shooting Pins/Needles Swelling Nausea

Please describe the location of your symptoms

Which activities make your symptoms worse?

Sitting Standing Bending Walking/ Running Turning Head

What makes your symptoms better?

Lying Down Ice Heat Stretching Nothing

What treatments have you already received?

Medication Physical Therapy Chiropractic Massage Blood Test NCV

Have you received any of the following special tests?

MRI X-Ray CT Scan Blood Scan NCV

Are you currently taking any medications?

Yes No

If you are taking medications, please list

PAST MEDICAL HISTORY

Are you a smoker?

No Yes, occasionally Yes, regularly

Do you drink alcohol?

No Yes, occasionally Yes, regularly

Do you exercise regularly?

Yes No

If you ever had any of the following, please check:

AIDS/HIV Allergies Anemia Ankylosing Spondylitis Arthritis Atherosclerosis Bronchitis Cancer Chron's Disease Emphysema

Epilepsy GERD Heart Disease Diabetes Mellitus Hepatitis Huntington's Disease Hypertension IBS Lupus Lymphoma

Meningitis Migranes Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Osteoporosis Parkinson's Disease Prosiatitis Psoriasis Rheumatism

Scleroderma Scoliosis Shingles Tay-Sachs Disease Tetanus Thyroid Disease Tinnitus Ulcers Vertigo Other

Others

Are you aware of any immediate family history of

Heart Disease Cancer Diabetes

FEMALE: Any chance that you are pregnant?

Yes No Not sure

Please list any past operations or surgeries (name of procedure and date)

Insurance Card Upload

Upload the front of Insurance card:

Upload the back of Insurance card:

ID Upload

Upload the front of ID Card:

The submitting process might take few more seconds, please do not exit until it’s done.

Our Mission

Move Well MD is on a mission to make movement and physical activity joyous for all. We are committed to providing our clients with the highest quality expertise in physical therapy and therapeutic exercise

Our Services

Acupuncture
Chiropractic
Joint Pain Relief
Physical Rehab
Back Pain
Neck Pain & Migraines

Shoulder Pain Relief
Trigger Point Injections
Knee Pain Relief
Sports Medicine
Physical Therapy
Sciatica

Contact US

+1 212-769-3210
info@movewellmd.com
150 Broadway #1213 New York, NY 10038

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