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This form is used to collect information about new patients and used for internal purposes only. The information you supply is confidential and will be treated accordingly.\nFirst Name: _____________________ Last Name: _____________________\nDate of Birth: ______________ Gender: \u0003☐\u0004 Male \u0003☐\u0004 Female \u0003☐\u0004 Other\nStreet Address: __________________________________________\nCity: _____________________ State: _____________________ ZIP Code: ________\nHome Phone: _____________________ Mobile Phone: _____________________\nSocial Security Number: _____________________ E-Mail: _____________________\nEthnicity/Race: _____________________ Weight: ________ Height: ________\nPrimary Language: \u0003☐\u0004 English \u0003☐\u0004 Spanish \u0003☐\u0004 Other: _____________________\nMarital Status: \u0003☐\u0004 Single \u0003☐\u0004 Married \u0003☐\u0004 Divorced \u0003☐\u0004 Separated \u0003☐\u0004 Widowed\nSpouse Name: _____________________ Spouse Phone: _____________________\nEmergency Contact Name: _____________________\nRelationship: _____________________ E-Mail: _____________________\nHome Phone: _____________________ Mobile Phone: _____________________\nPrimary Insurance Company: _____________________\nGroup #: _____________________ ID #: _____________________\nPrimary Insurance Type: \u0003☐\u0004 HMO \u0003☐\u0004 PPO \u0003☐\u0004 Medicare \u0003☐\u0004 Other: ______________\nComplete the following if you are not the policyholder for your primary insurance:\nInsurance Policyholder: \u0003☐\u0004 Spouse \u0003☐\u0004 Child \u0003☐\u0004 Parent \u0003☐\u0004 Other: ______________\nPolicyholder Name: _____________________ Date of Birth: ______________\nPolicyholder Social Security Number: _____________________\nSecondary Insurance Company: _____________________\nGroup #: _____________________ ID #: _____________________\nPrimary Insurance Type: \u0003☐\u0004 HMO \u0003☐\u0004 PPO \u0003☐\u0004 Medicare \u0003☐\u0004 Other: ______________\nComplete the following if you are not the policyholder for your secondary insurance:\nInsurance Policyholder: \u0003☐\u0004 Spouse \u0003☐\u0004 Child \u0003☐\u0004 Parent \u0003☐\u0004 Other: ______________\nPolicyholder Name: _____________________ Date of Birth: ______________\nPolicyholder Social Security Number: _____________________\nPrimary Care Physician: _____________________ Phone: _____________________\nList all other active treating physicians:\nPhysician Name: _____________________ Specialty: _____________________\nPhysician Name: _____________________ Specialty: _____________________\nPhysician Name: _____________________ Specialty: _____________________\nPhysician Name: _____________________ Specialty: _____________________\nList your allergies and describe the reactions to your body:\nAllergy: _____________________ Reaction: _____________________\nAllergy: _____________________ Reaction: _____________________\nAllergy: _____________________ Reaction: _____________________\nAllergy: _____________________ Reaction: _____________________\nList the medications you are currently taking including the dosage:\nMedication: _____________________ Dose: _____________________\nMedication: _____________________ Dose: _____________________\nMedication: _____________________ Dose: _____________________\nMedication: _____________________ Dose: _____________________\nList any major conditions/illnesses that your immediate family members have had:\nList any surgeries, fractures, major illnesses, or hospitalizations that you have had:\nHave you ever had any of the following?\nList any other medical problems that you have had:\nWhat’s your primary health concern? _____________________________________\nApproximately when did this issue begin? _____________________\nDoes the issue cause you pain? \u0003☐\u0004 Yes \u0003☐\u0004 No\nIf so, where? _____________________________________\nHow has the pain changed since it began? \u0003☐\u0004 Increased \u0003☐\u0004 Decreased \u0003☐\u0004 Unchanged\nHow quickly did you current pain begin? \u0003☐\u0004 Gradually \u0003☐\u0004 Suddenly\nHow often does your pain occur? \u0003☐\u0004 Constantly \u0003☐\u0004 Occasionally \u0003☐\u0004 Rarely\nWhen is your pain at its worst? \u0003☐\u0004 Morning \u0003☐\u0004 Afternoon \u0003☐\u0004 Evening \u0003☐\u0004 Night\nWhat a","cbCaifSl6rAgNRwU","https://ap.wps.com/l/cbCaifSl6rAgNRwU","docx",58586,7,"English","# Patient & Contact Information\n## Insurance Coverage\n## Medical History & Allergies\n## Current Medications\n## Symptoms & Pain Details\n## Lifestyle & Sexual Health\n## Pharmacy & Sign-off","[{\"question\":\"How does the form assess the patient’s current health concerns?\",\"answer\":\"It asks for the primary health concern, approximate onset time, whether there is pain, pain location, how pain has changed, onset speed, frequency, worst time of day, current symptoms, and related pain descriptors.\"}]","Patient Intake Form - New Patient Information | DOCX",1788324945]