Patient Medical History and Intake Form

Patient Medical History and Intake Form

Please complete this form to the best of your ability with the fullest level of detail possible so that we are best able to address your needs. If you have any questions about anything on this form please reach out to us at info@enduranceunleashed.com or call 919-516-9050
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
How did you hear about us?

Other
Who is your referring Physician/Specialist (if any)?
When did your condition start?
Please choose all that apply
What hurts or why are you filling out this form?
How did this condition start?
How much is the problem impacting your life?
Why are you looking to take care of this issue right NOW? (please be as detailed as possible so we are best able to address your needs)
What value would us helping you bring to your life?

Other
What goals/expectation do you have for your current condition? What would you like to get back to doing? (please be as detailed as possible)
Overall what would you say your quality of health is at this moment?

What has your pain level been over the past 24 hours?

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

What has your pain level been over the past week?

	1	2	3	4	5	6	7	8	9	10

1 is No pain, 10 is TAKE ME TO THE HOSPITAL NOW!!!

How often do you experience your symptoms?
Have you had any of the following services prior to filling out this form?

Other
Do you now or have you ever had any of the following?
Please explain any of the above "Yes" answers or describe any medical issues in detail below
Please verify that you are human
Signature
(MINORS ONLY) Checking this box below is a certification that the patient in question is a minor and I am responsible for their care. I hereby agree to informed consent to video/photograph this minor under my care.
Should be Empty: