NEW PATIENT INTAKE FORM

If you are interested in coming for a visit, please fill out the below and submit to our office.

Please email or bring any clinical reports, X-ray, CT scan, MRI, blood tests, or other information you feel is relevant.

 

Fill out the form below or

DOWNLOAD HERE and send via email or bring with you..

Name *
Name
Address
Address
Phone
Phone
Emergency Contact Phone #
Emergency Contact Phone #
HISTORY AND PRESENT EXPERIENCE
Please give a brief description
What are your goals and expectations?
Please provide a brief description and timeline.
Please provide a description and timeline, and results of the therapy.
Date/Medication/Effectiveness/Side Effects
Date/Supplement/Effectiveness/Side Effects
Could include anything that is currently stressful for you. Examples include relationships, job, school, finances and children.
HEALTH EVALUATION
i.e. coffee, tea, soda...
Please Describe
(include marriage, separation, divorce, traumatic events, losses, abuse)
FLUX NEUROLOGICAL SYMPTOMS CHECKLIST
Please rate yourself on the symptoms listed below using the following scale. If are unsure about any of the symptoms you can also have another person answer the question and place the initials (OP, other person) beside the question. 0=Never, 1= Rarely, 2= Occasionally, 3= Frequently, 4= Very Frequently
Please describe below
 
 

MUSCULOSKELETAL INTAKE QUESTIONNAIRE

We the clinic and staff are committed to serve our community in a professional clinical environment, and to empower patients to actively participate in their own healthcare. Flux recognizes and respects the self-aware, self-directed and self-healing nature of life and living beings. 

In order for us to be able to fully evaluate you, please take the time to complete the following intake form and questionnaires to the best of your ability. We realize there is a lot of information and you may not remember or have access to all of it; do the best you can. Fill out the form below and we will have it ready for your scheduled appointment. 

 

Fill out the form below or

DOWNLOAD HERE and send via email or bring with you.

Name *
Name
Address
Address
Home Phone #
Home Phone #
Work Phone #
Work Phone #
Please Describe Briefly
brief description and timeline
description, timeline and results of therapy
date, medication, effectiveness and side effects
date, supplement, effectiveness, side effects
Include anything that is currently stressful for you. Examples include relationships, job, school, finances, and children.
Any problems falling asleep? Any problems staying asleep? Any problems waking up?
Would you consider yourself mostly healthy or unhealthy? Any food allergies or sensitivities? Caffeine consumption per day? (i.e. coffee, tea, soda) Water consumption per day? Alcohol consumption per day? Describe your current bowel function. Describe your current digestive function. What do you typically eat for breakfast? What do you typically eat for lunch? What do you typically eat for dinner? What do you typically eat for snacks?
Are you or have you ever been exposed to consistent exposure to chemical toxins such as paints, molds, solvents, fumes, pesticides or heavy metals? Do you smoke? If so, how much and when did you start? Did you used to smoke? If so, for how long, and how much? Have you ever been consistently exposed to second-hand smoke? Do you ever have difficulty breathing? Do you often feel congested?
How much exercise are you getting per week? What types of exercise do you participate in? Is your current medical concern preventing you from participating in certain exercise activities?
Family Structure. Who currently lives in your household? Current marital or relationship satisfaction. Significant developmental events. (include marriage, separation, divorce, traumatic events, losses, abuse
Please rate your physical pain on a scale of 0 - 10, with 0 being no pain at all, and 10 being the worst pain Imaginable.