New Patient Intake Form | Please enter your information below to register as a new patient of . Please complete all forms. Contact InformationYour Name*Home PhoneCell PhoneEmail AddressAddress Line 2CityState*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming-AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanZipcode*County*Patient InformationSexPlease SelectMaleFemaleGenderPlease select if this is different from sex.Please SelectMaleFemaleOtherSpecify GenderYour Date of Birth (DOB)* Date Format: MM slash DD slash YYYY Height (Feet)Please Select3ft4ft5ft6ft7ft8ftHeight (Inches)Please Select0"1"2"3"4"5"6"7"8"9"10"11"Weight (lbs)Social SecurityLast 4 of Social SecurityProvince Health Insurance Plan ID UploadPlease upload a photo or a scan of your Province Health Insurance Plan ID Identification DocumentsPatient Registry Number (Optional)Drivers License #In which state is your drivers licensePlease SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDrivers License Photo/UploadPlease upload a photo or scan of your driver's license.Accepted file types: jpg, gif, png, jpeg, pdf.Medical Record DiagnosisPlease upload a photo or scan of your Medical Record Diagnosis.Emergency ContactEmergency Contact NameEmergency Contact's Phone #Primary Care PhysicianPrimary Care Physician NamePrimary Care Physician Phone #Guardian InformationIf the patient is a minor, please fill out the following information.Father's NameFather's Phone #Mother's NameMother's Phone #Caregiver's NameCaregiver's Phone #Current ConditionIf known, please tell us which condition are you currently seeking treatment for.Qualifying Condition– Fill Out Other Fields –Qualifying ConditionALSAlzheimer's DiseaseCancerEpilepsyGlaucomaHIVAIDSPost-traumatic Stress DisorderCrohn's DiseaseParkinson's DiseaseMultiple SclerosisChronic Nonmalignant PainAnxietyAnorexiaArthritisBipolarCachexiaChronic Fatigue SyndromeDiabetesEndometriosis/PMSFibromyalgiaHepatitis CIBSInsomnia/Sleep DisordersLyme DiseaseLupusMigrainesOCDRheumatoid ArthritisSickle Cell AnemiaUlcerative ColitisTourette's SyndromeSevere NauseaHuntington's DiseaseNeuropathiesOpioid Use DisorderAutismOtherNeurological DamageIntractable SeizuresInflammatory Bowel DiseaseNeurodegenerative DiseasesADHDHerniated Disk/SciaticSpinal StenosisGoutCancer TypeIdentify Terminal IllnessIdentify Pain TypeDescribe Qualifying ConditionDescribe the problem you would like addressed and when it started.Have you treated this problem before? How and when?Please list all illnesses and/or hospitalizations/surgeries you have had in the pastPlease list the name and dose of any current medication and/or additional supplements and vitamins you are takingPlease list any family history of diseasePlease list all known allergiesDo you currently use tobacco?Please SelectYesNoHave you used tobacco in the past?Please SelectYesNoDo you currently use recreational drugs?Please SelectYesNoAre you currently pregnant?Please SelectYesNoDo you exercise regularly?Please SelectYesNoHow many hours of sleep do you get at night?Rate your dietPlease SelectGoodFairPoorPlease select any symptoms/conditions you currently have Headache Change in taste, smell, hearing Slurred speech or speech problems Difficulty swallowing Dizziness Weakness Numbness Loss of Consciousness Fainting Seizure Falls Tremors Confusion Memory loss Head trauma Sleep-problems Stroke Fever Chills Fatigue Weight Gain Weight loss HIV/AIDS Blurry Vision Double vision Decreased vision Cataract Glaucoma Hearing loss Ringing in the ears Earache Vertigo Chest Pain Palpitations Leg edema High Blood Pressure Heart attack Coronary artery disease Shortness of Breath Heart failure Cough Emphysema Asthma Nausea Vomiting Heartburn Ulcers Abdominal Pain Diarrhea Constipation Rectal Pain Swallowing Difficulties Hepatitis Rash Eczema Joint pain/swelling Neck pain Back pain Muscle aches Depression Anxiety Agitation Nervousness Diabetes Thyroid problems Hormonal problems SignaturePatient Access CodeCommentsThis field is for validation purposes and should be left unchanged.